First name
Last name
Phone
Email
Preferred Method of Contact:
Phone
Email
Are you currently taking any medications? If so, please list them:
Are you disabled or on disability? If yes, please explain
What life controlling issues are you struggling with that you think we could help you resolve?
What substances are you currently using and how often do you use them?
Have you ever been in any recovery/treatment program?
Yes
No
If so, where? How long did you attend, and did you complete?
Do you have any outstanding warrants?
Yes
No
Have you had any sexual or violent crime charges?
Yes
No
Are you willing to commit 12 months of your life to this program?
Yes
No
Are you willing to commit to our Christ centered discipleship program to help you overcome life's hurts, habits and hang-ups?
Yes
No
On a Scale of 1 to 10 how ready are you for a life change?
Is there anything else that you would like to say regarding your application?
What date would you like to enter The Summit?
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Residential Application