Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Do you have children under age 18? *

Yes

No

Are you aware that Sound Mind, Inc., is a faith-based organization and that by agreeing to participate in our program, you also agree to participate in Bible studies and attend church as required? *

Yes

No

Emergency Contact Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Phone Number

(###)

###

####

Physician Phone Number

(###)

###

####

Are you currently experiencing any symptoms of withdrawal? *

Yes

No

Have you been in other recovery programs? *

Yes

No

When was the last time you were employed? *

MM

DD

YYYY

Are you able to provide payment for your stay at Sound Mind, Inc? *

Yes

No

Do you currently have any outstanding warrants? *

Yes

No

Are you currently involved with drug court, family court, or any other court system? *

Yes

No

By typing your name below you are e-signing this form and agree that the information contained within this form is accurate. Please type your name below and date to e-sign this application: *

First Name

Last Name

E-Sign Date *

MM

DD

YYYY