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- APPLICATION -

Please make sure your personal info is correct or it may delay the process. Please use your full legal name as it is on your birth certificate ID or CDIB card.

Gender
Marital Status
Are you a member or descendant of a Federally recognized Tribe?
Upload File
Upload File
Do you receive VA or SSI/SSD benefits?
Do you use substances or alcohol at least 4-5 days a week?
What substances are you currently using?
Have you ever overdosed?
Are you taking any prescription medications including psychiatric medications?
Has your substance use interfered or caused issues in your personal relationships?
Are you currently dealing with any court issue, misdemeanor, felony, or probation?
If yes, do you have permission from the court or your probation officer to receive treatment out of state?
Do you have any family or friends who support your recovery?
Are you in any immediate danger to yourself or others?
Are you currently living in a safe place?
Within the past two years have you tried to seriously harm yourself or attempt suicide?

Thank you for submitting! We'll be contacting you soon.

If you have not been contacted within 24-48 hours once you submit information, please call Carey Rafferty at (714) 679-9175

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