Apply for a Place

Intake Form

Complete this form as fully as possible. All information is strictly confidential and used only to assess your application.

Personal Details

First Name *

Last Name *

ID Number *

Date of Birth *

Phone Number *

Email Address

Room Preference

Shared Room

Shared with one other resident

Private Room

Your own room

Recovery Details

Fellowship *

Sobriety Date (if applicable)

Sponsor Name

Sponsor Phone

Are you currently working the steps? *

Substance history (what substances, how long, last use) *

Previous treatment or rehabilitation history

Medical Information

Any medical conditions we should be aware of?

Current medications (name and dosage)

Emergency Contact

Full Name *

Phone Number *

Anything else?

Tell us anything else relevant to your application

Important

By submitting this form you confirm that the information provided is accurate to the best of your knowledge. All information is treated with strict confidentiality.