Add Facility
Facility Name
Facility Street Address
Facility City
Facility State
Facility Zip Code
Facility Phone
Contact First Name
Contact
Last Name
Contact Email
*please note this is the email that will be used to distribute the ATLAS Treatment Facility Survey
Contact Phone
If you would like additional members of your team to receive emails on data collection for the Treatment Facility Survey for this facility, please enter their information below.
Number of Additional Contacts
Please select...
1
2
3
4
5
Additional Contacts
First Contact
1. First Name
1. Last Name
1. Email
Second Contact
2. First Name
2. Last Name
2. Email
Third Contact
3. First Name
3. Last Name
3. Email
Fourth Contact
4. First Name
4. Last Name
4. Email
Fifth Contact
5. First Name
5. Last Name
5. Email
Levels of Care offered at this facility (select all that apply)
Outpatient
Inpatient
Residential
Opioid Treatment Program (OTP)