Name*

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Email*

Phone*

I am a current AZZLY client/user.

Yes

Valued AZZLY Clients: Please provide your organization's Client ID. Your Client Services representatives are ready to help.*

Valued AZZLY Clients: Please describe the nature of your inquiry, or the issue you are experiencing. Your Client Services representatives are ready to help.*

Company name*

Company website URL

Job title

State/Region*

Which areas do you serve?*

Substance use disorders
Mental health
Eating disorders
Other

If you selected "Other", please specify which other area(s) you serve.

What levels of care does your organization serve?*

Residential
Medication-Assisted Treatment (MAT)
Opioid Treatment Program (OTP)
Outpatient (OP)
IOP (Intensive Outpatient)
Detox
Case management

Lastly, when would you like to make a change?

Phone

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Eating Disorders

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