Self-Assessment - Gallus Detox Centers

Please provide your first name(Required)

What is your Phone Number?(Required)

What is your date of birth?(Required)

What is your gender?

Male

Female

Non-Binary

Are you over 36 weeks pregnant?(Required)

Yes

No

How would you like to pay for treatment:(Required)

Commercial Health Insurance

Pay directly

Tricare/Medicare/Medicaid

Please choose the best way for our admissions team to connect with you(Required)

Call me

Text me

Email me

Email(Required)

Complete the following questions to confirm if you are eligible for medical detox.