Online application

Please complete this application and admissions will follow up with you regarding membership.

*If a question is not relevant to you, please answer "none" or "not applicable." 

Date of birth:

Is this a treatment facility? 

Sobriety date:

Are you currently enrolled in an outpatient program?

Do you currently have a therapist or counselor?

Employed since:

Requested move in date: 

Consent to contact?

Are you receiving treatment?

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