Apply to Acceptance House

Name*

E-Mail*

Phone*

Address*

City*

State*

Zip Code*

Drug of Choice*

How do you intend to pay for Acceptance House?*

Legal Issues?*

Are you required to register as a sex offender?*

Do you have any current medical conditions?*

List all current medication (Prescription and over-the-counter)*

Are you currently in treatment?*

If in treatment, where?

Have you ever been in treatment?*

If so, then where?

Expected move-in date:*

Emergency Contact Information:*