If you’ve made the decision toseek help, congratulations! You’re making the first step admitting youhave a problem.

If you are going to an inpatient/ outpatient treatment facility or recovery house, talk to the admissions counselor about your situation, chances are they already know us and will contact us on your behalf if necessary.

Otherwise, please email us a brief note describing who you are and what your situtation is in seekinghelp. We will definitley be incontact with you and send you any additional documents if necessary.

Again, congratulations! You’re onyour way to a whole new and wonderful life if you do what is necessary and keep your committment to stay clean and sober!

Eamil: info@leighshelp.org

Wherever possible, please have as much of the following information available to make processing your request for assistance as fast as possible.

___ Legal first name, middle name, last name?*
___ Maiden name, aliases if any?
___ Birth date?*
___ U.S. Citizen? Other citizenship?

___ Social Security number?*
___ Drivers License number/Gov’t I.D.? State?
___ Email address?
___ Cell phone number?

___ Primary Emergency Contact name, phone number, address?
___ Relation to you? Relative, friend, etc.?)
___ Alternate contact(s) info if available?

___ Employer name, address, phone number?
___ Contact (Human Resource manager or supervisor)?
___ Current employee? Full-time? Part-time?
___ U.S. Military Veteran?
___ Labor or professional Union affiliation/member if any?

___ Health Insurance carrier name, phone number, address? ___ Health Insurance Policy and/or Account Number?
___ Primary doctor/.physician name, phone and address?
___ List of doctor prescribed medications?

___ Name of last hospital you were admitted?

___ School name, phone number and address?
___ Student I.D. number?
___ Currently enrolled?

___ Bank name, phone number and address?
___ Account numbers? Checking? Savings?
___ Any credit cards you have?

___ Previous rehab or treatment center names, phone, address?
___ When you were last a patient?
___ Recovery program Sponsor, counselor/advisor?
___ Parole/Probation Officer name, phone and address?

*Required