RECOVERY BEGINS WITH ACCEPTANCE
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ABOUT US
HOW IT WORKS
THE RESIDENCE
APPLY ONLINE
CONTACT
ABOUT US
HOW IT WORKS
THE RESIDENCE
APPLY ONLINE
CONTACT
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?
*
Select
Self
Insurance
Family
Other
Legal Issues?
*
Select
Yes
No
Are you required to register as a sex offender?
*
Select
Yes
No
Do you have any current medical conditions?
*
Select
Yes
No
List all current medication (Prescription and over-the-counter)
*
Are you currently in treatment?
*
Select
Yes
No
If in treatment, where?
Have you ever been in treatment?
*
Select
Yes
No
If so, then where?
Expected move-in date:
*
Emergency Contact Information:
*
APPLY