Secure Individual Enrollment Form

1. Complete the form below.

Note: Connections is an application for smartphones, numbers provided for landlines will not work.

2. Once the form is submitted, you will receive a download link via text message within 24 hours or the next business day.

3. Download and install the application and read the User’s Guide.

4. Start using the Connections App, including daily check-ins, eTherapy, message boards and more!

    First Name *

    Last Name *

    Gender: *

    Date of Birth: *
    If you are on an iPhone and using iOS 14, you may need to double tap on the line below.

    Home Address *

    Home City *

    Home State *

    Home Zip *

    Email *

    Mobile Phone Number: *

    Emergency Contact Person First Name (FN) *

    Emergency Contact Person Last Name (LN) *

    Emergency Contact Person Phone Number: *

    Do you use tobacco products?: *

    Are you pregnant?: *

    I am an individual in recovery for a substance use disorder: *

    Primary Substance of use *

    Health Plan / Insurance (for informational purposes only. Your insurance will not be charged):

    Name of person who referred you to this program / leave us a comment.

    Be sure to double check your mobile phone number in the form. You will be receiving a text message from (610) 488-2461 with a link to download the Connections App