Application Request Form

General

First Name: Client first name

Middle Name: Client middle name

Last Name: Client last name

Transitioning From: Dropdown

Current Address: Client Address

City: Client City        State: Client State    Zip Code: Client Zip

Email: Client email     Phone Number: Client phone

Gender: Client gender

Schooling: Dropdown

Who Suggested Our Facility: Dropdown

How Long Have You Been Drug & Alcohol Free: Dropdown

Are You on DRT/MAT (i.e. Methadong, Suboxone...): Dropdown     Dosage: Text field

In the Past 30 Day*s Have You Attended any Self-Help or Recovery Groups: Dropdown

Are You Currently Pregnant: Dropdown     Due Date: Text field

Do you have parental/family support:Dropdown

Employment Status:Dropdown

Are you legally mandated/stiplulated to be living somewhere:Dropdown

Are you currently awaiting charges, trail or sentencing: Dropdown      Describe:Text field

Have you ever been charged with or convicted of any major crimes i.e. Murder, Arson or a Registered Sex Offender:

Dropdown            Describe:Text field

Any Additonal Information you'd like to submit: Text field

Health Insurance

Provider: Text field          Insurance Plan:Text field

***Thank you for your submittal one of out Intake Coordinators will contact you directly to speak with you furthur if their is availabiltiy at one of facilities***