| Name: |
|
| Address: |
|
| Phone: |
|
|
What is your Date of Birth?
Month:
|
|
| Day: |
|
| Year: (4 digit) |
|
|
List your drugs of choice?
Separate with commas:
|
|
| What is your usual occupation? |
|
| Are you willing to stay in this residential program for
as long as it takes to get well?(AT LEAST 10 MONTHS) |
YES
NO
|
| Are you OK with this being a faith-based program with Bible
Study and Church REQUIRED? |
YES
NO
|
| Are you on probation or have any pending legal problems? |
YES
NO
|
| If YES, please explain: |
|
| Email Address: |
|
|
