Westwood House Application
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What is your substance(s) of choice? List Below
When was your last relapse date?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you ever been clinically diagnosed with anything?
What kind of meetings do you attend? Do you have a sponsor?
Medication List/ Dosage
Are you currently employed?
Desired Move In Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you ever been convicted or arson or a sexual offense?
Yes
No
Are you able to pay weekly fee's of $225 and pay $200 move in fees
Yes
No
Insurance Carrier/ Plan
Submit
Should be Empty: