Land Of Goshen

Treatment Center

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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...

First Name

Social Security Number

Phone

Drug of Choice

Last Name

Date of Birth

Insurance Provider

Do you smoke?

Yes

Marital Status

Single

Married

Have you ever been diagnosed with a mental health condition?

Yes

If you answered yes, what is your mental health diagnosis?

Are you currently dealing with any medical issues?

Yes

If you answered yes, what medical issues?

Are you currently dealing with any legal issues?

Yes

If you answered yes, what legal issues?

Do you follow a specific religion/belief system?

Yes

If you answered yes, what religion?

Ethnicity

Do you need detox?

Yes

Highest grade completed in school?

Are you currently clean? If so, how long?

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

We'll get back to you ASAP!

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

APPLY NOW

81 TOWNSHIP RD #349 IRONTON, OH 45638

Tel: 1 (740) 442-7758

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