Contact Us: Family/Friend of a Woman in Need

Contact Residence XII:

Contact Us: Family/Friend of a Woman in Need

• Is there a woman in your life who is struggling with alcohol or drug addiction?
• Is your wife or girlfriend in denial that she has a chemical dependency problem?
• Are you concerned about a friend who is constantly getting drunk or high?
• Do you know the mother of a child who is acting erratically or constantly smells like alcohol?
• Are you worried about your elderly mother drinking and using prescription drugs at the same time?

Residence XII would like to help. Fill out the form below and we will mail you general information about our facility, our programs and other resources that may be helpful. Thank you for your concern!

1. Name:
2. Address:
3. City:
4. State:     Zip Code:

5. Telephone:
6. Email:

   I am a family member of a woman who may need the services of Residence XII.

    

   I am a friend or acquaintance of a woman who may need the services of Residence XII.

    

   I would like to receive more information by mail only.

    

   I would like an assessment counselor to call me.

    

   I would like to receive the Residence XII newsletters

7. 
   Please enter text from the box above: