Drug addiction alcoholism treatment alcohol abuse

>> I think I might have
     a problem

>> I have a family member
     who needs help

>> I have an employee who
     needs immediate care

Treatment

Online Admission

A Renascent counsellor will call you within one business day to complete the application process. If you have any questions, do not hesitate to call us at 1-866-232-1212. For eligibility and admission requirements, click here.

What motivated you to call Renascent?

Contact information for the person making the referral:

First Name:	Last Name:	Title:

Organization:

Business Address:	Province:	Postal Code:

Business Phone:	Cell Phone:	Email:

I'm making this referral on behalf of:
Company Union Employee Assistance Provider Insurer Other:

Contact information for the person being referred:

First Name:	Last Name:	Title:

Organization:		Occupation:

Date of Birth:	Gender:
	Male Female
Business Address:	Province:	Postal Code:

Business Phone:	Cell Phone:	Email:

Questionnaire

Have you referred someone to Renascent before? Yes No
Is this a mandatory referral? Yes No
Do you require rapid assessment and admission? Yes No
Do you require compliance reporting? Yes No