WOMEN’s
Walkabout Recovery

Titusville, FL 32796
(321) 264-4250

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

WOmen’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?

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.

WOMEN’sWalkabout Recovery

WOmen’s Prospective client form

WOMEN’s
Walkabout Recovery