Please fill out the form completely and honestly to the best of your ability. The answers you submit will be determining factors to your admittance but no single answer will be a determining factor*.

(*Sex offenders will not be admitted into Riverhouse)

  • 0 no motivation - 5 highly motivated

    Please give us an idea of how motivated you are toward your recovery.

  • Personal Information

  • Date Format: MM slash DD slash YYYY

  • Financials

  • Please enter a number greater than or equal to 50.

  • Previous and Current Legal Issues

  • Treatment Information

  • Please enter a number from 0 to 20.

  • Medical Information

  • Aknowlegements

    Please acknowledge that you meet or are willing to meet the following requirements by initialing next to requirement. If it is determined that this acknowledgment is false, the resident will be expelled from Riverhouse immediately
    I acknowledge and agree that as a member of the Riverhouse community, I must agree to a minimum commitment of three (3) month stay.