Skip to content

Enroll

doctor and patient talk prescription drugs addiction
Credit Card Authorization

General Info

Card Details

Authorization

I, , hereby authorize Windriver Recovery to debit/charge my credit card for amount listed below for SUD education services, I understand that there is a 3.5% charge for credit card payment

$
Client Face Sheet

Demographic and Identifying Data

Employer Information

In Case of Emergency

Financial (responsible party or indicate "self"

Agreement to Pay for Services
$

I , (Client name) have requested that Present Moments Recovery (PMR) provide Addiction Education services to me and I agree to pay a fee of $ for hours of Addiction Education services. I voluntarily agree to meet with PMR to obtain the required hours of education. I understand that if I miss a session without providing 24 hour notice, it will be considered an unexcused absence. I will be granted the opportunity to make up the session at a later date. Unexcused absences will result in $100.00 cancellation fee. I agree that this financial relationship with PMR is not reimbursable by insurance. I agree that I am responsible for the charges for services provided by PMR to me and understand the fee is due prior to the first session. The charges are non-refundable.

Get in Touch with Our Caring Team

We are waiting for your call. Don’t hesitate, pick up the phone and dial 619-363-4767 today.

Your first call will be greeted by one of our intake counselors who will be able to provide information on what program would be appropriate for your situation, as well as information about the process of getting treatment at our facility, if appropriate.

If Present Moments is the right fit for your current situation you will be speaking to Admissions Director Mark Gladden, who will be your guide throughout the process of arranging travel and undergoing an initial detox (if necessary). Mark has been the guide for dozens of men and women who have gotten their lives back by entering treatment at Present Moments. He has earned his reputation as being truly dedicated to the recovery of others. Mark will be the one to ‘show you the ropes’ when it comes to admitting to our facility for treatment

Homepage Form
dhcs-seal

You CAN Achieve Sobriety

We Are Here To Guide You