Apply

Please read our Program Overview and Member Handbook before submitting this application. Submit the form online below or download a Printable Version to send to us. Questions? Contact us.

Full Legal Name

Date of Birth

Phone

Address

Is this a treatment center?

Most Recent Treatment Facility Name

Facility Phone

Treatment Counselor Name

Counselor Phone

Treatment Dates

Gender

Employer

Employer Phone

Are you able to work?

List all sources of income

List Substance(s) you have abused

Date of last use

List any medical issues

List all medications

Spouse Name + Phone

Emergency Contact + Phone

Nearest Relative + Phone

Doctor Name + Phone

Are you a registered sex offender?

Are you on…

List any pending charges

List any prior convictions

Probation/Parole Officer

Probation/Parole Officer Phone

Do you own a car?

Is it legally registered in your name?

Do you have car insurance?

Make/Model/Color

Do you have a valid drivers license?

Drivers license number and state

Do you prefer a shared or private room?

How did you hear about us?

Other details we should know

I attest that all information submitted is true and complete to the best of my knowledge