Please answer these questions to see if you qualify for this program.

Please note, we are currently at capacity and will place each prospective client on a waiting list in the order they have applied.

Name

First Name

Last Name

Age

Date of Birth

YYYY

Sex

Phone

(###)

###

####

Do you have a valid drivers license?

Do you have a valid ID?

Do you take any medications?

What illicit drugs are you taking?

Please list your drug of choice.

If you are struggling with alcohol, how much are you drinking?

Do you have any outstanding legal issues?

Are you a registered sex offender?

Are you on Community Control or Probation?

Do you have a history of seizures?

Have you been diagnosed with epilepsy?

Are you on any anti-seizure medication?

Are you able to work?

Do you have any physical limitations?

How did you hear about us?

Additional Comments

If you are applying for someone other than yourself, please leave your name and contact information below.

I acknowledge that the program is at full capacity, by submitting my form this will place me in a queue to start the interview process.