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Initial Intake Application

Our purpose for the initial assessment is to gather basic information about you and the problems and pain that addiction has caused you and your loved ones. So we require that this form, ONLY be filled out by the person being assessed. if that is not an option at this moment, please contact us directly and we will be glad to help you.

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Step 1 of 6
Full Name
Gender
In case of an Emergency please contact... Name / Phone # / Relationship
Your Address - Most Recent
(city, state and zip code)