Residency Application

Only fill out out this application if you are willing to try a different way of life, to leave your old way of thinking behind and truly want to get better.
Full Admissions Packet
Is this the individual seeking recovery or is this being filled out by a 3rd party?(We will take this into consideration when reviewing your application)*
Today's Date*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email*
example@example.com
I.C.E. Person*
I.C.E. Phone Number*

Area CodePhone Number
I.C.E. Relationship*


DWI
Public Intoxication
Possession of a Controlled Substance
Possession with intent to deliver
Manufacturing
Prostitution
Theft
Burglary
Assault
Arson
Homicide / Manslaughter
Fraud
Other


Primary Care Physician
Last Dr.'s visit?
Explain:
Are you currently being treated for any physical problems?
Explain:
Please list all medications you are currently taking:
Allergies(specify):

Psych-Social Questionnaire


Officer's name and contact number
Charge
Sentence