Application

Please Call to confirm we received your applicatin.

Please read the policy PDF under the Documents page

* Indicates required field

Name *

First

Last

Email *

Cell phone Number *

Date of Birth *

Marital status *

Children, If yes, Ages *

Driver's License (state & number) *

Are you currently in treatment? If yes, date of admission and location *

Current centers contact information (address, email, and phone number) *

Requested Move-in Date *

Sobriety anniversary date *

Alcohol & Drug of abuse *

EMERGENCY CONTACT info *

2nd EMERGENCY CONTACT Info *

Are you currently on any medications? If yes, please list name and dosage *

Allergies? *

Current Employer info *

Highest level of education? Are you currently in school? *

Do you currently have any pending legal cases? If yes, what are the charges?Untitled *

Are you currently on probation or parole? If yes, what were you convicted of? *

Do you have a medical doctor? If yes, please provide contact info. *

Current medical conditions? Include any psychiatric history *

Insurance Provider, Group ID, Policy number, primary holder of insurance *

Person responsible for residential fees if accepted *

Type your name below if you have read and understand the policy *

I understand entry fees are not refundable after acceptance *

I understand

Apply

Contact Info

Phone 203.449.0753
Email: [email protected]