Application


CURA, INC.

ADMISSIONS APPLICATION

CURA Inc. is a Non-Profit Organization that provides Substance Abuse and Behavioral Health Services in an Outpatient, Short Term or Long Term Capacity. By completing the form below you are expressing an interest in being considered for admission into any one of these programs.  CURA, Inc. complies with all Federal and State mandates with regards to confidentiality and privacy laws. Please allow three business days for the Intake department to review and respond to your application.

Application (480)

Contact Information
  1. (required)
  2. (required)
  3. (required)
  4. (required)
  5. (required)
  6. (required)
  7. (required)
  8. (required)
Status Information
  1. What language would you prefer these services be provided in?
  2. Are you homeless:
  3. Who is your healthcare provider:
DRUG/ALCOHOL/TABACOO USE
  1. Do you smoke:
LEGAL STATUS
  1. Are you under the supervision of a probation/parole officer at this time?
REFERRAL SOURCE
 

cforms contact form by delicious:days