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Home The Cure KAC Program Check-in Process What You Can Expect Daily Schedule Contact

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First Name: *
Last Name: *
Address:
City:
State:
Zip:
Day Phone Number: *
Evening Phone Number: *
Email address: *
Is this inquiry for yourself?    Yes No
(If Yes)
Are you being referred by a Doctor, Courts or Family?
Are you ready to invest 28 days for a life for sobriety?

If not for you, enter the name of the person you are concerned about:

Last Name:
First Name:

What is the addict's relationship to you?  

What is the age of the addict?  

Briefly Describe the drug history of the addict:
What problems has addiction caused the addict?
What problems has addiction caused the family?
What kind of help do you think the addict needs?
What is the worst problem addiction has caused the addict?
Other Information:
Please describe briefly what is going on with this person right now. Please add any other info you think we should know (i.e. best time to call)
* Would you like to receive more information on addiction?
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