Intake form

Help us serve you better

Name *

Email address *

What services are you interested in?

Please select at least one option.

Sober Living

Mental Health Rehabilitation

Addiction Recovery

What is your current living situation?

Have you previously received treatment for addiction or mental health issues?

If yes, please specify the type of treatment received.

What is your primary goal for entering our program?

Do you have any known allergies or medical conditions?

Are you currently employed?

What is your highest level of education completed?

Please list any skills or certifications you possess.

How did you hear about hopeful horizons?

Additional questions or comments

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Hopeful Horizons