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Application for Regenerate Your Authentic Nature Treatment Program
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Name
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First
Last
Email
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Phone Number
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Your Birthdate mm/dd/yyyy
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Children
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No
Age of Children
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Please list ages of children
Are you willing to commit to 1 year program?
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Days without Drugs/Alcohol
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List any Medications Currently Taking
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Describe past experience with recovery, drug of choice and age of first use.
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Describe current / past legal issues
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Psychiatric history-diagnosis & medication history. Specify number of years on prescribed medication(s)
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Please complete the application form to submit for review by R.Y.A.N. Hope House.
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