Application Form

Someone from our team will be in touch with you to follow up and answer any questions you may have. Upon acceptance into the program, you will have our full support through your journey toward recovery.

 

Name: *
Name:
Primary Phone Number:
Primary Phone Number:
Secondary Phone Number:
Secondary Phone Number:
mm/dd/yyyy
Gender:
Marital Status:
Children:
Do you drink alcohol?
Previous attempts at recovery? *
Any emergency room visits or hospitalizations within past year for medical, psychiatric or substance abuse?
Reason for hospitalization:
Any suicide attempts in the last year?
What is motivating you to seek treatment at this time?
Emergency Contact: *
Emergency Contact:
Emergency Contact Phone Number: *
Emergency Contact Phone Number: