Length of Stay?

The amount of time someone stays at Summer House varies depending on what the patient is using, how much and for how long and age. Other pre-exising health issues other than drugs and alcohol also play a factor in determining the length of stay so please be as thorough as possible when filling out this form. Privacy Policy: This information is private and will never be shared with any other organizations.

How Did You Hear About Us?

First Name

Age

Email Address

Phone Number

Are You Drinking Alcohol?

Are You Taking Drugs?

Are You On Any Medications?

Explain A Little About Your Drinking, Explain in Detail... How Much and How Often?

What Drugs or Medications Are You Currently Taking and How Much? ...Explain In Detail and include Everything!

How's Your Health?... Please Explain Any Health Issues.

How Should We Contact You?

= Required

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