Please fill out all fields.   A member of our Staff will contact you upon receipt of your Pre-application. Thank You.

Name *
Name
Phone Number *
Phone Number
Date of Birth *
Date of Birth
Address *
Address
Emergency Contact *
Emergency Contact
Contact Phone *
Contact Phone
Did you receive a recent medical Detox? *
Date of Discharge
Date of Discharge
Are you an Alcoholic? *
Are You an Addict? *
Date You Last Used or Drank *
Date You Last Used or Drank
Are You on Probation, Parole, or Currently Incarcerated? *
Do You Have Any Outstanding Warrants? *
$450.00 Fee is Required Upon Entry to Our Program. Will You be Responsible for your Fees? *