Alabama Drug Rehab, Alabama Alcohol Rehab, ALDrugRehab at Rapha Ministries

"If thou wilt diligently hearken to the voice of the Lord thy God, and wilt do that which is right in His sight, and wilt give ear to His commandments, and keep all His statutes, I will put none of these diseases upon thee, which I have brought upon the Egyptians: for I am (Rapha) the Lord that healeth thee"

Exodus 15:26

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Rapha Ministries, Inc & Rapha Christian Home Online Application for Program Entry

Please fill out the form completely and accurately so that we may complete your request. If you would rather use the printable application and mail it or fax it to us click here for the printable version.

Name (Last-First-Middle)

Address

City

State

Zip Code

Telephone (Home)

Telephone (Work)

Email Address

Social Security#

Birth Date

Legal Background

Medical Background

Medications you are taking now

Drug Abuse Background

CLIENT'S MUST HAVE AT LEAST 72 HOURS CLEAN TIME BEFORE 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

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!