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A little about our Program
About Us (Staff & Board)
Application Form
Application Form
*
Indicates required field
Name
*
First
Last
Phone Number
*
Birthdate
*
Email
*
Do you currently have a driver’s license?
*
Yes
No
Drivers License Number
*
Do you currently have a vehicle?
*
Yes
No
Social Security #
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Any Medical Conditions? Please List Below
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Are you Married?
*
Yes
No
Do you have children?
*
Yes
No
Any medications you are currently taking.
*
Please List drug of choice (DOC) Below: (example- Alcohol, Cocaine, Prescription Drugs)
*
When was the last time you used drugs or alcohol?
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Have you been in a recovery program before:
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Yes
No
Ever attended any meetings (AA, NA, Celebrate recovery):
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AA
NA
Celebrate Recovery
None
Have you ever been arrested?
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Yes
No
Misdemeanor convictions:
*
Felony convictions:
*
Do you have any warrants, pending charges and or upcoming court dates?
*
.1 Emergency Contact (name and number):
*
Currently on probation, parole, under bond? (if yes please list probation or parole officer name and contact info below)
*
Submit
Home
A little about our Program
About Us (Staff & Board)
Application Form