Breakup Rehab Application
Hello and Welcome to Breakup Rehab

Breakup Rehab is 6 month program that requires an commitment of time and money. Not everyone will qualify for this program as it is conducted over the phone and necessitates a level of mental stability. Provisions can be made to meet in person and details will be discussed if it’s determined you are fit for the program.

It should be understood that while phone sessions may seem therapeutic they are not intended as therapy but rather as spiritual and holistic counseling. It should also be understood that results are dependent upon the applicant to the program.
Please answer these questions to see if you qualify for Breakup Rehab.

Email address *
What is your desired outcome for the program? *
Will you be able to abstain from drug use, alcohol use, smoking marijuana or tobacco during 12 weeks of Breakup Rehab? (Be honest--lying will immediately disqualify you from receiving treatment.) Please list what Rx drugs you are currently taking, the milligrams, who is prescribing your medications, and how often you take your Rx meds. *
Your answer
What is your history of romantic partners? *
Please describe your current financial situation and means of income.
Your answer
Please describe your current living situation.
Your answer
Why do you want to enroll in Breakup Rehab? *
Your answer
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