ADMISSIONS APPLICATION

Applicant Information

Address Details

  • Are you a US citizen?
Marital Status
Race
  • Do you read at a 5th grade level or above?
  • Do you have a high school diploma?
  • GED?
  • Do you have any relatives or friends currently in our program?
  • Have you previously been in our program?
  • Do you use tobacco?
  • Have you ever been treated at an addiction recovery facility?
    Details of 1st Facility
    Dates of treatment (mm/dd/yyyy):
    • Did you complete the program?
    Details of 2nd Facility
    Dates of treatment (mm/dd/yyyy):
    • Did you complete the program?

Physical Health

  • Are you currently being treated by a doctor?
    Dates of treatment (mm/dd/yyyy):
  • Are you pregnant?
  • Allergic to Medication?

IMPORTANT: Applicants on prescribed narcotics will need to complete the regimen prior to admission or switch to non-narcotic pain medications.

Please list all NON-Psychiatric medications currently prescribed to you:

Medication Reason Dosage

Special Needs

  • Do you have any type of disability?
  • Do you have any chronic conditions?
  • Do you have any medical restrictions?
  • Do you have any type of special needs?
  • Do you have any allergies?
  • Do you require a special diet?

Dental/Vision Health

  • Do you have any dental issues that need treatment?
  • Do you wear glasses or contacts?
  • Do you have your glasses or replacement contacts?

Mental Health

  • Have you ever been treated for mental disorders?
  • Have you ever been treated by a psychiatrist/psychologist?
    Dates of treatment (mm/dd/yyyy):

Please list all Psychiatric medications currently prescribed to you:

Medication Reason Dosage
Please tell us of any current mental/emotional health concerns you may have:
  • Have you thought about or attempted suicide in the past 6 months?
Mental Health History (check all that apply to your current and past conditions)

Legal Issues

  • Are you currently on probation?
    Please enter information about your Probation Officer:
  • Are you currently on parole?
  • Do you currently have court cases pending?
  • Are you currently under investigation?
  • Do you have any outstanding warrants?
  • Have you ever been convicted of a violent crime?
  • Are you currently facing charges for a violent or sex-related crime?
  • Are you required to register as a sexual or predatory offender?
  • Do you have an Attorney?
    Please enter information about your Attorney:
Legal History (check all that you have been involved with)
If other, please list

Emergency Contact

Financial Information

  • Are you presently employed?
  • Do you receive any other income (SSI, disability, etc)?
  • Do you currently receive government assistance?

Program Fee Information

Applicant's Certification And Agreement


  • Program Policies and General Information
  • Room and Board Fee Information
  • Prohibited Medication