APPLICATION FOR ADMISSIONS: RESIDENTIAL PROGRAM Register Now: Name of person filling out this form (required) Relation to patient(required) Best time to reach you? 1:00 am 2:00 am 3:00 am 4:00 am 5:00 am 6:00 am 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12:00 noon 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm 8:00 pm 9:00 pm 10:00 pm 11:00 pm 12:00 midnight (required) What time zone?(required) At what number?(required) OK to leave message? Yes No (required) Email(valid email required) Client Information Client name (first, middle, last)(required) Date of birth(required) Gender Male Female (required) Marital Status Never Married Married Divorced Separated Widowed (required) Email Address(valid email required) Please tell us... How did you hear about us? Professional Referral Internet Alumni Friend / Family Member I am a previus Crossroads client Word of Mouth Other: List professional referrent, search engine, etc... General Comments Please include a brief description of your situation below. Information disclosed in your application will be kept strictly confidential. An admissions counsellor will contact you within one business day to complete your application process and help assess your needs.