Your Path Recovery Living Application
I hereby apply for Membership in YOUR PATH Recovery Living, and provide the following information for use by house Members and YOUR PATH Recovery Living, in determining my eligibility and appropriateness for Membership.
Your Path Recovery Living will consider all requests for reasonable accommodations.
Name: Client first name Client last name
Date of Birth: Client birthdate
Current Address: Client Address
Phone Number: Client phone
Email: Client email
Estimated Discharge Date: Client discharge date
Diagnosis: Client diagnosis
List of Medications: Medication
Subastance of Choice: Client substances of choice
Treatment Center History: TreatmentCenterHistory
Why do you want to be a Member of YOUR PATH Recovery Living?
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If accepted as a Member what are your goals from living at YOUR PATH Recovery Living?
Signature