Your Name (Last-First-Middle) *required

Address *required

City *required

State *required

Zip *required

Home Telephone *required

Work Telephone *required

Your Email *required

Birth Date *required

Legal Background

Medical Background

Medications You Are Taking Now

Drug Abuse Backgroun

ASSESSMENT MUST INDICATE MINIMAL RISK OF SEVERE WITHDRAWAL AT ADMISSION!

Be sure of your commitment!
If for any reason you leave this program before completion….there will not be a pro-rated refund given.

Date *required

Upon receipt of this submission form a Rapha staff member will be contacting you with a follow-up call to verify your information and application request for program admission.
Thank You!

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