PLEASE PROVIDE US WITH THIS INFORMATION

Name

Date

Age

ID/DL #

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 name

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!

Thanks for your interest in Footprints to Recovery. This information will help us in getting to know you and will not be shared with anyone. Plus it's a jump start on our entrance paperwork!! Can't wait to meet you :)
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