Application 2018-04-16T13:42:21+00:00


About You:

*denotes a required field

First Name:*   Middle Initial:*   Last Name:*   Date of Application:*
Desired Move In Date:*   Birthdate:*   Phone:*   Email:*
Street Address:*   City:*   State:*   Zip:*



About Your Addiction:

Do you mainly need help with:* Alcohol AddictionDrug AddictionGambling AddictionOther:(enter below)
What is your drug of choice:*   Date of last use:*   Substance used:*


Are you currently enrolled in a treatment facility?* YesNo
If yes, please complete the following:   Treatment Center:   Counselor's Name:
Counselor's Phone:   Counselor's Email:   Date of Expected Completion


Are you considering, or have you been approved for,
any outpatient/aftercare treatment?* YesNo
  If yes, where:



About Your Health:

List any physical limitations:*   List any current medical concerns:*
List all prescriptions you currently take:*
Medication name:   Reason:
Medication name:   Reason:
Medication name:   Reason:
Medication name:   Reason:
Medication name:   Reason:
Medication name:   Reason:


Is there anything else you’d like us to know about you?



About You:

*denotes a required field
First Name:*
Middle Initial:*
Last Name:*
Date of Application:*
Desired Move In Date:*
Birthdate:*
Phone:*
Email:*
Street Address:*
City:*
State:*
Zip:*


About Your Addiction:


Do you mainly need help with:* Alcohol AddictionDrug AddictionGambling AddictionOther:(enter below)
What is your drug of choice:*
Date of last use:*
Substance used:*


Are you currently enrolled in a treatment facility?* YesNo
If yes, please complete the following:
Treatment Center:
Counselor's Name:
Counselor's Phone:
Counselor's Email:
Date of Expected Completion


Are you considering, or have you been approved for,
any outpatient/aftercare treatment?* YesNo
If yes, where:



About Your Health:

List any physical limitations:*
List any current medical concerns:*


List all prescriptions you currently take:*


Medication name:
Reason:


Medication name:
Reason:


Medication name:
Reason:


Medication name:
Reason:


Medication name:
Reason:


Medication name:
Reason:




Is there anything else you’d like us to know about you?