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Lakeview Recovery Community

Admission Application Form

We understand that seeking help is a significant and courageous step, whether for yourself, a client or patient, or a family member. 

Our team is committed to providing a supportive, confidential, and compassionate admissions process for all individuals who are ready to embark on their recovery journey.

Confidentiality Assurance

We prioritize your privacy and are committed to maintaining the confidentiality of all applicants. Rest assured that any information you provide during this process will be handled with the utmost care and discretion, adhering to all relevant privacy laws and standards.

Who Can Refer?

  • Self-Referral: If you feel that you need support in overcoming addiction or other challenges, you can directly apply yourself.
     
  • Professional Referral: Healthcare providers, counselors, social workers, and other professionals can refer their clients or patients who may benefit from our services.
     
  • Family Referral: Family members concerned about their loved one's well-being can also submit a referral on their behalf.

Admissions Form

Applicant Information

Personal Information

Full Name
Birthday
Gender
Address
Preferred Method of Contact

If someone other than the subject is filling out this form, please provide the following details:

Role:

Consent and Agreement