Mahajan Therapeutics: Contact Form

Contact Us

Please select an option to request an appointment, request sober living accommodations, or share your recovery story.
Reason for Contact*

Request an AppointmentRequest Sober LivingShare Your Recovery Story

Request an Appointment

Fill out the following form to request an appointment at Mahajan Therapeutics.
Title*
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Diagnosis/ Reason for Appointment*
Select Location*
Insurance Type*
How did you hear about us?

GoogleSocial MediaPrimary Care DoctorHospitalCourt RepresentativeSchoolOther

Request Sober Living

Fill out the following form to request sober living at Mahajan Therapeutics.
Referral Information
Referring Name*
Referring Source / Company*
Referring Email*
example@example.com
Patient Information
Patient Name*

First NameLast Name
Patient Phone Number*
Please enter a valid phone number.
Patient Email*
example@example.com
Patient Date of Birth*

MonthDayYear
Date
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Diagnosis*
Date of Sobriety*

MonthDayYear
Date
Sober Home Location

Dayton, OHPortsmouth, OH

Share Your Recovery Story

Fill out the following form to share your recovery story at Mahajan Therapeutics.
Full Name

First NameLast Name
Email
example@example.com
How did you hear about Mahajan Therapeutics?

ReferralSocial MediaRadioOther
What made you seek help?
How did Mahajan Therapeutics help you?
What advice would you offer someone in need of mental health or addiction support?
Do we have your permission to share your story in our marketing efforts*

YesNo

Contact Us