Smiling Family

APPLY ONLINE

Changing perspective - Finding hope. You are not alone.

ONLINE APPLICATION

Fill out the form below to quickly apply to Land of Goshen Treatment Center online! We'll take a look over your application and get in contact with you as soon as possible to help get you into treatment.

Land of Goshen Treatment Application

Please fill out the following form so we can better assist you...

Do you smoke?
Marital Status
Have you ever been diagnosed with a mental health condition?
Are you currently dealing with any medical issues?
Are you currently dealing with any legal issues?
Do you follow a specific religion/belief system?
Do you need detox?

We'll get back to you ASAP!

Feel free to contact us if you need help filling out the application...