Confidential Admission Inquiry

Please complete the confidential Admission Inquiry Form below. This form is used for inquiries regarding alcohol and drug addiction, process addictions, codependency, and other recovery concerns. The information you provide will help us better understand your situation and determine whether Serenity Vista may be the right fit for your individual needs.

All inquiries are handled with the utmost privacy and confidentiality. After reviewing your submission, we will contact you promptly by telephone or email to discuss your situation, answer your questions, and explain the recovery options available.

Please complete all required fields marked with a red asterisk (*).

After clicking Submit Form, please wait a few moments for the confirmation message to appear. This lets you know your inquiry has been successfully received.

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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Confidential Admission Inquiry

Ready For Change?

Into Action

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

Canadian Residents:
‍For a limited time, enjoy a 10% fee reduction to help offset exchange rates.

Contact Us

Confidential Admission Inquiry

Ready For Change?

Into Action

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

Canadian Residents: ‍For a limited time, enjoy a 10% fee reduction to help offset exchange rates.Contact Us

Contact Us Now

Canadian Residents:
‍For a limited time, enjoy a 10% fee reduction to help offset exchange rates.

Contact Us