WOMEN’S APPLICATION

    Women's Application

    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?