Apply Fill out the form below to submit your application. Once submitted, we will get back to you as soon as possible. Name(Required) First Last Date of birth(Required) MM slash DD slash YYYY How many treatment centers have you been to? What are you going to do differently this time in your recovery if this is not your first time getting sober? How long have you been sober? What is your longest period of recovery? What is your substance of choice? Which treatment facility are you currently in? (If not in treatment, please provide current residence information) Do you have any mental health issues? If so, please list all of them. Do you take any medications? If so, please list all of them. Do you have any current or past criminal charges? If so, please list all of them. Are you on state or county parole? If yes, please select state or county. Do you have a sponsor? Yes No Are you willing to go to 12 step meetings and work a program of recovery? Yes No Do you have any money saved or financial support for rent? Yes No Do you have a vehicle? Yes No Please provide me with your contact number and email and/or your counselors if you’re still in treatmentYour PhoneYour Email Emergency Contact(Required)NamePhone Add Remove
