Back on Track Resale Shop and Addiction Ministry



Back On Track Addiction Services

Rehab Placement Assistance Form

Please fill in all fields. If a field is not applicable to you, please fill in "NA"

CONTACT INFO
First name*
Last name*
Email*
Phone*
Street Address1
City
State
Zip
Date of Birth

ABOUT YOU

Race

Sex at Birth

MALE

FEMALE

Drug of Choice

Months of Use

All Current Charges

Currently on Probation or Parole?

YES - Probation

YES - Parole

If so list the following:

Attorney

Probation Officer

YOUR PLANS

Current Court Dates:

Release Date

Please describe any insurance disability or Medicare you have:

Please list any mental health disorders that are pre-existing or exacerbated by substance abuse:

Please list medications currently prescribed:

Are you willing to commit to a 4-12 month program?

YES

Name and Phone of a family member or friend we can call:

Do you affirm that all of the information you have provided is true to the best of your ability?

YES

Do not enter anything in this field:

* indicates a required field

Please fill this field.

Back on Track Ministries

STORE HOURS:
Monday-Saturday, 9am-5pm

IN PERSON DONATIONS:
Monday-Saturday, 9am-4am

ABOUT US

Back on Track Addiction Ministry is a 501c3 charity. We fund our services through financial donations and the sales from our resale store. We accept donations of clothes, housewares, furniture, jewelry, collectables, antiques & more. We are an independent organization serving Henderson County, NC and beyond and not affiliated with any government, church or religious organizations.

Visit Us:

Back on Track Resale Shop & Addiction Ministry
1900 Spartanburg Hwy
Hendersonville, NC 28792
828.595.9091