• 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.

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  • Full Admissions Packet

  • Today's Date*
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    2 digit month, 2 digit day, 4 digit year
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  • Forms of Identification*
  • When was the last time you used any alcohol or drugs?*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Psych-Social Questionnaire

    This questionnaire is designed to provide us with information to better assist you. Please answer each question as completely as you can. Feel to add comments.

  • Personal Alcohol / Drug History

  • What was your drug of choice?*

  • Alcohol / Drug History *
    Rows

  • Education / Employment

  • Legal History

  • Are you currently on probation or parole?*
  • If you are, please fill out the following information:
    Rows
  • Please indicate how many times you have been arrested for the following
    Rows

  • Personal Medical History

  • *
    Rows
  • Hospitalizations
    Rows

  • Marital / Family History

  • Children
    Rows

  • Spiritual Status

  • Other Concerns

  • By Agreeing to the terms & conditions, you are agreeing to adhere to the following:                          

    • Workout Agreement                       
    • Psycho-social Questionnaire                               
    • Chore Captain Responsibilities        
    • House Rules                                                  
    • Smoking Agreement
    • Big Brother Policy
    • Sponge Mode
    • House Discipline Process
    • Social Media Agreement

    All of these agreements can be found in the Application

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