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 DoradoElyriaFamily Recovery Solutions - MansfieldFamily Recovery Solutions - Mt. CarmelFamily Recovery Solutions - Port MatildaFamily Recovery Solutions - SelinsgroveFamily Recovery Solutions - WilliamsportHuber HeightsLake CharlesLewisvilleMetairieMiddlesex Recovery - ChelmsfordMiddlesex Recovery - GloucesterMiddlesex Recovery - StoughtonMiddlesex Recovery - WoburnMiddletownMonroeNashvilleNorton Health Care - NortonNorton Health Care - SalemOakdalePlanoRichmondSlidellThibodauxWilloughbySelect 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 Clinic Louisiana Baton RougeT: 225.208.2000 Bossier CityT: 318.716.3814 Lake CharlesT: 337.513.4844 Metairie T: 504.535.4200 MonroeT: 318.582.2335 Oakdale T: 318.252.8877 Slidell T: 985.260.2001 ThibodauxT: 985.243.1822 Kentucky Bowling Green T: 859.780.5793 Crestview HillsT: 859.780.5793 Middletown T: 270.229.6402 Virginia RichmondT: 804.409.3866 Ohio Elyria T: 440.472.1924 Huber Heights T: 937.401.2789 WilloughbyT: 440.336.8465 Tennessee NashvilleT: 615.205.3577 Texas LewisvilleT: 469.470.1151 PlanoT: 972.954.4585 Arkansas El DoradoT: 870.639.4527
