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