Treatment Profile → this is a Dropbox option, and bold indicates heading, and non-bold are the selectable options (need the ability to select more than one)
Seeking help for: Self, Significant other, Daughter, Son, Friend, Other
Desired Treatment Setting: Detox, Inpatient Rehab, Outpatient, Medication-Assisted Treatment, Residential Treatment, Unknown
Problem with (Drug): Alcohol, Cocaine/Crack, Marijuana/Hashish, Synthetic Cannabinoid, Heroin, Other Opiate/Synthetic, Alprazolam (Xanax), Other Tranquilizer, Synthetic Stimulant, Other Stimulant PCP Ecstasy, Other Hallucinogen, Inhalant, Ketamine, Over-the-Counter
County of Residence: Albany, Rensselaer, Schenectady, Other
Schedule an Appointment: Yes or No [if yes, prompt to: Name, Phone Number, Best Time to call: Morning, Afternoon, Evening; Weekday or Weekend
Here’s why you should choose Our Village Services: Treatment Connection