Name:________________________________________________________________________

Last

First

Middle

Address:______________________________________________________________________

Street

City

State

Zip Code

Telephone:____________________________________________________________________

Home

Work

Other

Social Security #:_________________________

Birth Date:___________________

Legal Background:____________________________________________________________

____________________________________________________________________________

Medical Background:__________________________________________________________

____________________________________________________________________________

Medications you are taking now: ________________________________________________

____________________________________________________________________________

Drug Abuse Background (drugs you use)_________________________________________

____________________________________________________________________________

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.

____________________________________________

_________________________________

Applicant Signature

Date