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Application Form
First Name*
Last Name*
Phone*
Email*
Date Of Birth*
Desired Move In Date*
Clean / Sober Date*
Drug Of Choice*
Heroin
Other Opiates
Alcohol
Benzos
Cocaine
Marijuana
Other
Do You Take Any Of The Following Prescription Medications?*
Suboxone (is an approved medication)
Methadone (is an approved medication, provided Client doesn't posses more than 1 day's dose and doesn't 'nod' or seem intoxicated)
Any Opiate EXCEPT Suboxone including: Vicodin, Norco's, Oxy/Hydro: morphine/morphone/contin etc.
Any Stimulant including: Adderall, Ritalin, etc.
Any Benzodiazepine including: Xanax, Valium, Klonopin, Ativan etc.
NONE OF THE ABOVE
Other
Are you In Treatment Or Attending IOP/PHP?*
Yes
No
Which Treatment or Recovery Center (IOP)? (Or None) *
Who Referred You To Destiny Estates *
Other Information
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