Seeking Safety

A Treatment Program for PTSD and Substance Abuse

Now available in a judgement-free, friendly place…

The Norristown Hospitality Center

Self Referral

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Last Name

First Name

Date of Birth (YYYY-MM-DD)

Last 4 of SSN

Why do you want to join Seeking Safety?

Address

City

State

Zip code

Email Address

Phone #

Agency/Professional Referral

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Client Last Name

Client First Name

Date of Birth (YYYY-MM-DD)

Last 4 of SSN

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PTSD (Post Traumatic Stress Disorder)

SUB (Substance Use Disorder)

Address

City

State

Zip code

Email Address

Phone #

Referring Agency

Referring Person (first and last name)

Referring Person Phone #

Referring Person Email

Seeking Safety

A Treatment Program for PTSD and Substance Abuse

Now available in a judgement-free, friendly place…

The Norristown Hospitality Center

Self Referral

Your message has been sent

Agency/Professional Referral

Your message has been sent

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