Contact Us
Please select an option to request an appointment, request sober living accommodations, or share your recovery story.
Reason for Contact
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Request an Appointment
Request Sober Living
Share Your Recovery Story
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Request an Appointment
Fill out the following form to request an appointment at Mahajan Therapeutics.
Title
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Name
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First Name
Last Name
Phone Number
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Format: (000) 000-0000.
Email
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Date of Birth
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Address
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Street Address
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State / Province
Postal / Zip Code
Diagnosis/ Reason for Appointment
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Select Location
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Please Select
Dayton Center Mental Health
Dayton Center Alcohol and Drug Addiction
Wheelersburg Center
Portsmouth Center
Ironton Center
Insurance Type
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How did you hear about us?
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Request Sober Living
Fill out the following form to request sober living at Mahajan Therapeutics.
Referral Information
Referring Name
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Referring Source / Company
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Referring Email
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example@example.com
Patient Information
Patient Name
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First Name
Last Name
Patient Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email
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example@example.com
Patient Date of Birth
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Year
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Patient Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Diagnosis
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Date of Sobriety
*
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Month
-
Day
Year
Date
Sober Home Location
Dayton, OH
Portsmouth, OH
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Share Your Recovery Story
Fill out the following form to share your recovery story at Mahajan Therapeutics.
Full Name
First Name
Last Name
Email
example@example.com
How did you hear about Mahajan Therapeutics?
Referral
Social Media
Radio
Other
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
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Additional Comments
Please share anything else that you would like for us to know.
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