Admission Form | Wilmington NC & Myrtle Beach SC Recovery Home

Name *

Last *

Email *

Date of Birth *

SSN

Closest Relative

Relative's Phone

Current Residence *

Anticipated Arrival Date *

Have You Lived in Launch Pad Before? *

Driver's License or ID Card Number

Have You Been to Prison? *

If Yes, Please Explain When, Where & Why

Handicap/Disability Needs (if any)

Current Medications *

Drug(s) of Choice *

Length of 12-Step Involvement *

Pending Court Dates

Have you been convicted of a sex crime? *

Type of Employment You Have or Want

If you are human, leave this field blank.