[text* Name placeholder “Name”]
[email* E-Mail placeholder “E-Mail”]
[tel* Phone placeholder “Phone”]
[select DrugofChoice “Drug of choice (select…)” “Alcohol” “Club Drugs” “Cocaine” “Fentanyl” “Hallucinogens” “Heroin” “Inhalants” “Marijuana” “MDMA (Ectasy/Molly)” “Methamphetamine” “Opiods”]
[select* SelectInsuranceType “Insurance Type (select…)” “Employer Funded” “Self-Funded” “Medi-cal/Medicare” “No Insurance”]
[submit “Send”]
1
Cycles of Change Form
[Name]
mhunter@cocrehab.com
Name: [Name]
E-Mail: [E-Mail]
Phone: [Phone]
Drug Of Choice: [DrugofChoice]
Insurance Type:[SelectInsuranceType]
Reply-To: [E-Mail]

Cycles of Change Recovery Center “[your-subject]”
Cycles of Change Recovery Center
[your-email]
Message Body:
[your-message]

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This e-mail was sent from a contact form on Cycles of Change Recovery Center (https://cycleschange.wpengine.com)
Reply-To: admin@cyclesofchangerecovery.com

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