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Celebrate Freedom Application
Answer all questions and include a phone number so we can call you back.
Date of Birth
If a mental health, recovery, or medical agency referred you to us, which specific one?
Address that you currently call "home."
What other options other than Celebrate Freedom at 10124 E. 46th St. are you considering?
Cocaine / Crack
Heroin / Fentanyl / Other Opiates
Thc / Marijuana
Spice / Synthetic Marijuana / Bath Salts
Antidepressants / Sleep narcotics
Employer if any
How will you pay your program fee?
Tell us about current legal issues.
Will you be on probation, parole, electronic monitoring?
What prescription medications will you be bringing?
What medical or emotional issues give you the most trouble?
Who is your emergency contact? (along with phone number)
What is your emergency contacts email?
Who should we update about your progress (along with phone number or email)?
What are your beliefs about God?
A copy of your responses will be emailed to the address you provided.
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