Keystone Structured Living Application for Admission

As per Federal Confidentiality Regulations: all records, information and communications shall remain strictly confidential.

Name*

Address*

City | State | Zip*

Phone | Email*

Email*

Male or Female*

Date of Birth (xx/xx/xxxx) Age*

Are you currently in a Treatment center or Detox? If so, list the name of the facility.*

Are you alcoholic, drug addict or both? Drug of choice?*

Are you on any medications? If so, please list them here.*

Are you physically and mentally able to work a full time job?*

Have you ever lived, or are you currently living in sober living? Is so, where?*

Are you currently taking Suboxone or Methadone*

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Keystone Structured Living

10265 Browning Drive Baton Rouge, LA. 70815

225.450.7659 KeystoneSLBR@Gmail.com As per Federal Confidentiality Regulations: all records, information and communications shall remain strictly confidential.

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