Read entire Resiliency Room Statement before starting intake process.

For Admissions Counselor to Read Aloud:

If you are not dedicated to wellness you have no place with us. You are making a commitment to the One World Wellness Tribe for life. If you are not honest, we can not help you. You will find out that you are not healing if you don’t do your work with us. We have lots of people that need our attention and we don’t appreciate being side tracked by falseness. We will send you away and you can move along. This is not forced treatment. You are here on this planet voluntarily.

Name:

Age:

Groups You are Affiliated With:

Drug use:

Craving Information:

Relevant Trauma:

Environmental Hazards:

Family Conditions:

Symptoms:

Previous Diagnoses:

Do you want a referral to a Pharmacist/Herbalist Medical Doctor or a residential treatment program and a coach?