Follow the steps to complete your application with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your personal information in the designated fields. Fill in your name, including last, first, and maiden/middle names. Ensure to select the appropriate gender.
3. Provide your physical address, including city, state, and zip code. If different, include your mailing address as well.
4. Indicate your county of residence, contact numbers, and employment status. If employed, fill in the employer's information.
5. Complete the sections regarding your education, marital status, race/ethnicity, and if you are a veteran.
6. Fill in details of your emergency contact, including their relationship to you and their phone number.
7. Answer questions regarding dependent children, annual family income, health insurance, and whether you receive SSD/SDI.
8. Provide details on your current substance use, including any withdrawal symptoms you may experience, and if you have tried to address these issues previously.
9. Complete the assessment section, which includes your physical health, any known medical issues, and current medications.
10. For the addiction counselor section, answer questions related to your treatment history and complete the DSM-5 diagnoses if applicable.
11. Review your information for accuracy and completeness before proceeding to save, download, print, or share the form.

Complete your application online today to begin your path to recovery.