Addiction Crisis Help

If you or a loved one are in immediate physical danger, please call your local emergency services.

For 24-hour immediate assistance in a crisis situation please contact our Program Coordinator at (866)460-9014.


Name
Home Phone
Work Phone
Fax Number
Other Phone Number
Email Address
Best time to reach you
Street Address
City
State
Zip Code
Relationship to Participant
Participant Information
Participant Name
Participant City
Participant State
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.


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, West
Virginia, Wisconsin, Wyoming

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

Southworth Associates is a proud member of both the Association of Intervention Specialists (AIS) and the National Association of Addiction Treatment Providers (NAATP).

Association of Intervention SpecialistsNational Association of Addiction Treatment Providers
W3C Validated
Intervention Recovery
Intervention