Please complete the application below, so that we might have a better idea of how best to serve you and to prepare for your stay.
Name:
Client first name Client last name
Gender:
Client gender
Date of Birth:
Client birthdate
Current Phone:
Client phone
Primary Email:
Client email
County of Residence
Text field
Tribal Affiliation (if applicable)
Have you served in the Military?Text field
Referred By:
What is your current living situation?
Dropdown
Preferred Move in Date:
Date
Counselor:
Substances of Choice:
Client substances of choice
RecoveryHistory
TreatmentCenterHistory