Registration form
Addiction Recovery Coach Online (ARCO), Ecolink Institute of Well-being          
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Email *
Full Name
Name of the patient
Place of the patient (State and City)
Gender of the patent
Age of the patient
Phone number of the patient
Your Mobile number
Your email
Which therapy you would like to choose for the patient?
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Has he/ she ever taken a residential treatment for addiction before?
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Which language you prefer for the therapy?
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What is your relationship with the patient?
Personal Indemnity: I have gone through the details of the therapy and is willing to recommend the above patient to undergo all sessions, both individual and group therapy, and support his journey to recovery. By Submitting the form, I agree to the terms and conditions
Terms and Conditions: https://www.ecolinkinstitute.com/arco-tnc
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