Synergy Treatment Centers - Program Application

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Applicant Name *

State of Residence *

Applicant Phone Number *

Alternate Contact Name *

Alternate Contact Phone Number *

Alcohol and Drug History *

Civil and Criminal History (include past convictions and pending cases) *

Physical and Mental Health History (medications taken within the past 5 years and past and present mental diagnosis) *

Why is long term (6 months - one year) treatment desired? *

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