MEN’s
Walkabout Recovery

112 S. Brown Ave.
Titusville, FL 32796
(321) 264-4250

Walkabout Recovery is a 9-12 month men’s faith based residential treatment program. We hope to provide a safe, open, honest and transparent environment where men struggling with drug and alcohol addictions can find a new way to live.

currently, We are at capacity and will place each prospective client on a waiting list in the order they have applied.

men’s Prospective client form

Please answer these questions to see if you qualify for this program.

Name

First Name

Last Name

Age

Date of Birth

YYYY

Phone

(###)

###

####

Do you have a valid drivers license?

Do you have a valid ID?

Do you take any medications?

If yes, please list all medications and dosage

If not on any meds now, please include any medications you have been on in the past year that you feel you should be on now.

What illicit drugs are you taking?

If you are struggling with alcohol, how much are you drinking?

Do you have any outstanding legal issues?

Are you a registered sex offender?

Are you on Community Control or Probation?

Do you have a history of seizures?

Have you been diagnosed with epilepsy?

Are you on any anti seizure medication?

Are you able to work?

Do you have any physical limitations?

I acknowledge that the program is at full capacity, by submitting my form this will place me in a queue to start the interview process.

Yes

How did you hear about us?

Additional Comments

If you are applying for someone other than yourself please leave your name and contact information below.

MEN’sWalkabout Recovery

currently, We are at capacity and will place each prospective client on a waiting list in the order they have applied.

men’s Prospective client form

MEN’s
Walkabout Recovery