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* 1. Please enter your contact information

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* 2. What counties does your facility contract with? (Check all that apply)

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* 3. In what service areas do your clients reside? (Check all that apply)

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* 4. What genders are served at your facility

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* 5. What ages does your facility provide treatment services to?

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* 6. Do you accept (check all that apply)

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* 7. Who is able to make referrals for services at your facility (select all that apply)

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* 8. Does your facility have programs designed to serve any of the following populations? (check all that apply)

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