Confidential Application

This is a confidential application. Fill in all the applicable information below and hit summit. If your application is approved, a copy of this will be signed in the presence of the director of Good Samaritan Rehabilitation, or an authorized delegate of the director and will be kept on file by Good Samaritan Rehabilitation.
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    This is a 120 day program for women and 60 day for men. All contracts will be terminated after 30 days unless otherwise approved by the Director. This is only an application. It will be reviewed by the Director or an authorized representative and you will be contacted by phone. Thank you.