PLEASE PROVIDE US WITH THIS INFORMATION
Current phone #:
How did you hear about us?
Current living situation
Drug of Choice
Date of last use
Are you currently working a 12 step program?
If so which one?
Sponsor phone #
Past/Current psychiatric diagnosis
Are you currently under a mental health professionals care?
Please list your medications
FEEL FREE TO GIVE US A SHORT BIO AND TELL US ABOUT YOURSELF!