Contact Southworth Associates Addiction Interventionist

For 24-hour immediate assistance in a crisis situation, intervention help or addiction counseling, please contact our Program Coordinator toll-free at (866) 460-9014. International callers need to dial +1 208-891-4726.

Or

For non-emergency questions or concerns please call our main office toll-free at (800) 386-1695. International callers need to dial +1 208-323-9555.

You may also reach our office by filling out the form below:
Please note that this information is held strictly confidential (see bottom of page)

---

Name
Home Phone
Work Phone
Fax Number
Other Phone Number
Email Address
Best time to reach you	Select Morning Afternoon Evening
Street Address
City
State	Select Outside the USA Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming
Zip Code
Relationship to Participant
Participant Information
Participant Name
Participant City
Participant State	Select Outside the USA Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming
Who referred you to John Southworth or Southworth Associates?
Referring Party:
Referring Contact Name:
Describe your concerns:

As per Federal Confidentiality Regulations: all records, information and communications shall remain strictly confidential, except under the following circumstances: 1.) To authorized medical personnel, if a medical emergency exists, 2.) If the individual is a danger to themselves or others, 3.) Suspected instances of child abuse or neglect may exists, 4.) The individual or responsible party signs a release of information. Any violation of Federal Confidentiality Law and Regulations may be reported to the United States Attorney for the Judicial District in which the violation occurs.

---

 

Intervention Services • Southworth Interventions • John's Story • Our Goals • Types of Addictions
Medical & Professional Interventions • Testimonials • Resources • Contact an Interventionist • 12 Steps

An intervention is a planned interaction or interface to transform reliance on a destructive substance or conduct.

Interventions, Family and Professional, Treatment Referrals • Web Development by Webconsuls