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?