Who are you signing up for DynamiCare?

We’d like to get to know more about the person you’re signing up to use our service.


The more information you can provide us about your goals, the better our recovery coaches can serve your needs.

Their Name *
Their Name
What is the full name of the person you are signing up?
Their Phone
Their Phone
We collect contact information so we can reach out to the person you are signing up for an onboarding call after the service is purchased. Contact information will not be used in any other way.
Our minimum age is 13 years old. Signups younger than 18 years old will require special permission from parents.
How is this person doing in their recovery and why should they use DynamiCare? The more information you can provide the better - thank you!
Do they know you are signing them up? *
This helps give our team context when we are reaching out to this person for their first onboarding call!
Disclaimer *
DynamiCare is not a form of treatment or substitute for treatment, and does not provide treatment, but can be used as an adjunct to treatment or as a standalone wellness program to help people achieve healthy goals in relation to substance use.

Schedule a Consultation - Call us at 855-539-6264 (9am-5pm ET)