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Residential Drug and Alcohol Recovery Program Enrollment

Submitted by admin on Wed, 2014-11-26 17:13

Please complete the form below to begin the admissions process for enrollment at Discovery Place.

(*indicates required field)

First Name *

Last Name *

Phone Number *

Please include area code.

Email Address

Date of Birth

Year

Month

Day

Address

City

State

Zip Code

Drug of Choice

What are you willing to do to get sober? *

Leave this field blank

RESIDENTIAL RECOVERY PROGRAM INQUIRY FORM

We love to hear from people who need help. It's our passion to give back! Whether it's a simple question about substance abuse, or a complicated matter requiring immediate assistance, request a call or ask a question with the form below.