PLEASE PROVIDE US WITH THE FOLLOWING INFORMATION:

-Name

-Date of Birth

-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 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!

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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