Admissions Form

Please complete the information below. A Caron Admissions Specialist will contact you within 1 hr of your online form submission. If you are filling this form out between 11 pm and 7 am EST, a Caron Admissions Specialist will contact you by 8am EST unless you give us another specific time. If you are looking for immediate assistance please call 800-854-6023, someone is available 24 hrs/7 days a week.

For those seeking treatment for yourself or a loved one, this is a secure and private form.

* Required Information

Loved Ones' Information
Date must be entered as mm/dd/yyyy
Your Information
Date must be entered as mm/dd/yyyy
Please include area code (e.g., 555-555-5555)
(Please note: Caron calls appear as "CC" on Caller ID)