A place to call home
PLEASE PROVIDE US WITH THE FOLLOWING INFORMATION:
-Date of Birth
-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 professional's care?
-Please list ANY medications you are currently taking
...AND FEEL FREE TO GIVE US A SHORT BIO AND TELL US ABOUT YOURSELF!