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?