Apply for Residency – Divine Spirit LLC

Phone

This field is for validation purposes and should be left unchanged.

Date of birth(Required)

How many treatment centers have you been to?(Required)

What are you going to do differently this time in your recovery if this is not your first time getting sober?(Required)

How long have you been sober?(Required)

What is your longest period of recovery?(Required)

What is your substance of choice?(Required)

Which treatment facility are you currently in? (If not in treatment, please provide current residence information)(Required)

What is your discharge date? (If not in treatment, please provide your anticipated move-in date)(Required)

If so, please list your insurance provider.(Required)

Do you have any mental health issues? If so, please list all of them.(Required)

Do you take any medications? If so, please list all of them.(Required)

Do you have any current or past criminal charges? If so, please list all of them.(Required)

Are you on state or county parole? If yes, please select state or county.(Required)

Your Phone(Required)

Your Email(Required)

How did you hear about us?(Required)