Contact Info

First Name

Last Name

Phone Number

Address, City, State, Zip Code

Email Address

Date of Birth

About You

Race

Sex at Birth

Male

Female

Drug of Choice

Months of Use

All Current Charges

Currently on Probation or Parole?

No

Yes - Probation

Yes - Parole

If so, please list the following

Attorney

Probation Officer

Court Dates

Release Date

Please describe any insurance disability or Medicare you have:

Please list any mental health disorders that are pre-existing or exacerbated by substance abuse:

Please list medications currently prescribed:

Are you willing to commit to a 4-12 month program?

Yes

No

Name and Phone of a family member or friend we can call:

Do you affirm that all of the information you have provided is true to the best of your ability?

Yes

No