Choose Healing, Choose Recovery, Choose Rondeau Shores. Program Registration Personal InformationName(Required) First Last Date of Birth(Required) Month Day Year Phone(Required)Email(Required) Preferred Contact Method(Required) Phone Email Either Emergency ContactContact Name(Required) First Last Contact Relationship(Required)Contact Phone(Required)Reason for Seeking TreatmentWhat substance(s) are you seeking treatment for?(Required)Brief description of current challenges:(Required)Have you attended treatment before?(Required) Yes No Where and when?(Required)Health and SafetyDo you have any current physical health concerns?(Required) Yes No What current physical health concerns do you have?(Required)Do you have any mental health diagnoses?(Required) Yes No What mental health diagnoses do you have?(Required)Do you have any mental health concerns?(Required) Yes No What mental health concerns do you have?(Required)Are you currently on any medications?(Required) Yes No What medications do you currently take?(Required)Do you have any legal restrictions?(Required) Yes No What legal restrictions do you have?(Required)Do you have any allergies?(Required) Yes No What allergies do you have?(Required)AvailabilityWhen would you like to begin the program?(Required) Within a month ASAP! Are you available for a 14-day stay?(Required) Yes No Additional NotesAnything else you'd like us to know?
