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Online Introduction Form

The purpose of this page is to help women, such as you, take the first step in exploring whether Gracenter’s Licensed Recovery Residence is the supportive environment you are seeking for your long-term recovery.  Please complete the form below and click the “Submit” button below. 

Your First Name:
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Your Last Name:
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Your Phone #:
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Today's Date:
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Your Email Address:
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Are you willing to join a community of women in residence to support each other in maintaining recovery and other common goals?
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Are you willing to develop follow through with an individual recovery plan and participate in recovery monitoring, case management, 12-step program, and other supportive services?
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Are you willing to seek and maintain employment, job training, education, or volunteer work?
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Have you been clean and sober for 90 days?
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If you answered "no," how many days of sobriety do you have now?
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Tell us something about [1] yourself and your recovery and [2] why you are interested in Gracenter's program.(*)
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