Do you, or a loved one have a substance addiction and need help? Complete our form below and
tell us your story, and we will contact you to discuss the ways in which we can assist you.
I Need Help
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Please note : All information provided will be treated as confidential.
Your Details
Your Name
*
Contact Number
*
Email
*
Suburb/ City / Town
*
Province
*
Select a Province
Eastern Cape
Free State
Gauteng
KwaZulu Natal
Limpopo
Mpumalanga
Northern Cape
North West
Western Cape
Addict's Details
Addict's Name
Your relation to Addict
*
Select your relation
Self
Parent
Sibling
Child
Spouse
Friend
Other
If other, please state
Addict's Age Group
*
Select an age group
10 to 12
13 to 16
17 to 20
21 to 25
26 to 30
31 to 40
40+
Addict's Sex
*
Select Sex of Addict
Female
Male
Duration of Addiction
Substances used
Has Addict been for Rehab before?
Select an Option
No
Yes
If yes, how long ago?
If yes, at which facility?
Description
Give us a brief description about your situation
Preferred means of contact
*
How should we contact you?
Email
Telephone
Convenient time for us to contact you
*
Select a Time
Mornings (Mon - Fri 08:00 - 12:00)
Afternoons (Mon - Fri 12:00 - 17:00)
Evenings (Mon - Fri 17:00 - 20:00)
Any Time (Mon - Fri 08:00 - 20:00)
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