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234-571-9503

info@restoreaddictionrecovery.com

2650 Sanitarium Rd. Akron, OH 44312

**If you would like to send mail to a specific resident in our program, please email us and we can provide directions on the best way to do this so that your mail gets to them in a timely manner.**

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Please fill out the form below to begin the intake process at Restore Addiction Recovery

1

Contact Info

2

Legal Info

3

Medical Info

"*" indicates required fields

First Name*

Last Name*

Current Age*

Date of Birth*

Phone Number*

Where does the applicant live? Who does he live with?*

Is the applicant currently working and where?*

Insurance Provider (Medicaid, Private, None, Other)*

Date Last Used Substance*

Age Use Started*

Substances Currently and/or Previously Used (Select as Needed):

Has the applicant had heavy meth use in his past?*

Has the applicant received treatment prior? When, where?

	Currently Use	Previously Used
Alcohol
Cocaine
Heroin / Fentanyl
Hallucinogens (LSD, etc.)
Inhalants (Glue, Gas)
Marijuana
Meth
Prescription Medications
Nicotine
Other