Apply Online Legal Name * First Last * Last Date of Birth * Email * Phone * Current Address * City * State * ALAKARAZCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip * Date of Last Use * Drug of Choice * How do you intend to initially afford your stay at the retreat? * Parents/Family Assistance Outside Scholarship / Grant Savings OtherOther Do you have any current legal issues? * No Yes If so, please explain the issues. Do you have a criminal record? * No Yes If yes, please list the charges. Are you required to register as a sex offender? * No Yes Do you have any current medical conditions? * No Yes If so, please explain the conditions. List all current medication (prescription and over-the-counter). Are you currently in detox? * No Yes If so, where? Expected date of entrance? * Have you been in treatment in the past for alcohol/drug addiction? * No Yes If so, where? Do you have any allergies? * No Yes If so, please describe allergies. Emergency contact information * Contact's Name Emergency contact information * Contact's Phone Emergency contact information Contact's Address Where did you hear about Providence Retreat? * Internet Detox Referral Past Guest Other Specify Explain what made you decide to ask for help and what you are hoping to get out of your experience at Providence Retreat. * I am willing to commit to 28 days to complete the program. * Agree I will communicate any changes to the information that is provided in this application * Agree If you are human, leave this field blank.
