Provider Referral If you would like to refer a patient to an AppleGate Recovery clinic, please complete the following form and an admission professional will be in touch as soon as possible.Caller informationName*Relationship to patient*Phone*Select treatment center*Select treatment center *Baton RougeBossier CityBowling GreenCrestview HillsEl DoradoElyriaHuber HeightsLake CharlesLewisvilleMetairieMiddletownMonroeNashvilleOakdalePlanoRichmondSlidellThibodauxWilloughbyBest time to callBest time to callMorning (before 12 PM)Afternoon (12 PM - 5 PM)Night (after 5 PM)Email* Patient/Client InformationFirst Name*Last Name*Date of birth Date Format: MM slash DD slash YYYY GenderMaleFemaleMarital statusDrugs of choice*Your message*How did you hear about AppleGate Recovery?How did you hear about AppleGate Recovery?AlumniProfessional ReferralDoctor/HospitalFriend/Word of mouthSAMHSA SiteSearch Engine (Google, Bing)Suboxone.comCAPTCHA Call Your Nearest ClinicLouisianaBaton RougeT: 225.208.2000MonroeT: 318.582.2335Bossier CityT: 318.716.3814ThibodauxT: 985.243.1822Lake CharlesT: 337.513.4844ArkansasEl DoradoT: 870.639.4527KentuckyCrestview HillsT: 859.780.5793OhioHuber HeightsT: 937.401.2789ElyriaT: 440.472.1924WilloughbyT: 440.336.8465TennesseeNashvilleT: 615.205.3577TexasLewisvilleT: 469.470.1151PlanoT: 972.954.4585VirginiaBlacksburgT: 540.274.2235RichmondT: 804.409.3866
