Hope starts here.

Apply Online

Name

First Name

Last Name

How you heard about us

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Call back #

Must be a reliable # where we can reach you at anytime

(###)

###

####

Email

Please provide a reliable email address so we can contact you

Emergency contact

First Name

Last Name

Emergency contact #

(###)

###

####

Describe your current crisis

Have you hit rock bottom?

Describe your current legal situation

Are you a registered sex offender?

Will you give up tobacco products

Yes

No

Will you commit to 10 month or more?

Yes

No

What drugs are you currently using?

Have you ever had mental health diagnosis? If so for what?

Are you currently taking prescription medication? If so list below

List the names of any current medication you are taking and for how long

Upon completion of the intake process, our primary focus shifts to assessing the applicant's genuine willingness to change. Once you have completed the application form, our Director of Admissions will initiate contact with you. Subsequently, you will participate in a telephone interview to review program guidelines and discuss your commitment to the program process. Following this, a face-to-face interview will be scheduled.

Apply today to start your recovery journey for yourself or a loved one.

Hope starts here.

Apply Online