Serenity Vista Addiction Rehabilitation Admission Inquiry

Please complete the full addiction rehabilitation admission inquiry form below. This is a general inquiry form. It serves for alcohol, other drugs, process addictions, and codependency treatment. Completion of this form will help us access your situation and the suitability of Serenity Vista for your individual needs. We will follow up with you promptly by telephone or email to discuss your recovery treatment options.

Your privacy and confidentiality are assured and secure.

Please be as thorough as possible. Note that fields with a red asterisk * are required and must be completed to submit the form.

After pressing the ‘Submit Form’ button, please be sure to wait a few moments. You will see a short ‘ Thank you‘ message to let you know your form was submitted successfully.

Full Name *Street AddressAddress Line 2

City

State / Province / Region

Zip / Postal Code

Country

Email *

Phone Number

Age *

Children (if yes, please indicate ages)

OccupationWho referred you, or, how did you hear of or search for us?Briefly state what you are seeking or want help with *Have you gone to a rehab or had any other form of treatment or help for addiction before? *YesNoDescribe your history of drinking, drug use, and/or other addictive behavior (e.g. gambling, food or other behavioral compulsions, etc.). Include amounts, frequency, last use, and whether you are able to stop on your own for periods of time. If you drink alcohol regularly, when was the last time you went for more than 24 hours without a drink and did you have any negative effects? * Smoking history, past & present * List any health (physical or mental health) problems or diagnoses you have had, and specify conditions you currently receive treatment for *List any medications you are taking *What do you hope to achieve as a result of going to rehab? *Anything else you think is important for us to know?Serenity Vista is a non-smoking facility. Those that smoke must agree to participate in Serenity Vista's smoking cessation as part of their abstinent based recovery program. *I understand that Serenity Vista is a nicotine product free facilitySerenity Vista is a private, self-pay facility independent from insurance companies. *I understand the Serenity Vista program is private payProvide your consent *I have reviewed and agree to Serenity Vista Policies

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Serenity Vista Addiction Rehabilitation Admission Inquiry

Ready For Change?

Into Action

We are here to help you take the first steps toward your new life

* Next available opening is February 7, 2025. Book now to reserve your addiction treatment recovery program. *

Contact Us

Serenity Vista Addiction Rehabilitation Admission Inquiry

Ready For Change?

Into Action

We are here to help you take the first steps toward your new life

* Next available opening is February 7, 2025. Book now to reserve your addiction treatment recovery program. *Contact Us

Contact Us Now

* Next available opening is February 7, 2025. Book now to reserve your addiction treatment recovery program. *

Contact Us