First Name *

Last Name *

Date of birth *

Email

Phone *

I agree to terms & conditions provided by The Fourth Dimension. By providing my phone number, I agree to receive text messages from the facility.

Have you ever been to The Fourth Dimension before or any other recovery residence? If so, when was your most recent? *

Will you be transitioning from an institution? *

Correctional Facility

Detox

Residential Treatment

N/A

Have you ever been arrested for any sexual crimes? *

Yes

No

Are you willing to make a commitment to getting a sponsor, working the 12 steps, sponsoring other individuals, and attending 90 meetings in 90 Days in the program of Alcoholics Anonymous? *

Yes

No

Please list all medications and amounts you take for any reason.

1
2
3
4

If you are prescribed medications, are you able to self administer medication?

Yes

No

Do you have any known warrants anywhere in the U.S.? *

Yes

No

Are you taking medicated assisted treatment meds? (Suboxone, Methadone, Vivitrol) *

Yes

No

If yes, are you willing to seek medical treatment (Detox) from those (MAT) substances?

Yes

No

Have you been diagnosed with any mental illness *

Yes

No

Input the Date of last use of any mind altering substance, legal or illegal. *

Are you on fixed income? *

Yes

No

Are you physically able to work full time upon intake? *

Yes

No

Are you or a family member able to pay $100 intake fee? Yes or No (this answer will not disqualify you for being considered for acceptance into our program) *

Yes

No