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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