Please list all treatment programs, including detoxes, that you have participated in:
Are you currently experiencing any physical health or mental health symptoms?
Are you currenly working with a sponsor?
How long have you been in recovery?
What is your substance of choice?
Are you currently employed?
Last grade completed in school?
Vocational certifications/licenses
Please include at least two emergency contacts?
By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.