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Need Help?Jen Harp2021-12-06T21:20:43+00:00

WE HAVE BEEN WHERE YOU ARE AT.

We understand and we want to help. No judgement, no shame, we will walk alongside you and give you the tools you need to stay clean and sober and build a healthy life. Fill out the application below and we will get back to you soon.

First Name *

Last Name *

Email *

Age *

Full Address *

Phone Number *

Ethnicity: Are you Hispanic or Latino?

Yes

Prefer not to Answer

What is your race? Please select all that apply.

This is information is used for program demographic tracking and reporting only.

American, Indian Indigenous Person, or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

White

Middle Eastern or North African

Prefer to self-describe

Prefer not to answer

Please enter your self-described race.

Marital Status

Military Status

Do you read and write English at a 5th grade level or above? *

What addiction do you need help with? *

Last day of use? *

Substance(s) used? *

Do you use tobacco? *

Have you ever been treated for addiction? *

If so, how many times?

Do you have any type of disability? *

If yes, please list.

In your own words tell us why you want to come into East Bay Men's Recovery Center. *

Please list all medications you are taking: *

Please list any chronic conditions you have: *

Do you have any other type of special needs? If yes, please list. *

Are you currently on probation? *

Do you have any outstanding warrants? *

Have you ever been convicted of a violent crime? *

Have you ever been convicted of a sex related crime? *

Please list anything else you want us to know: *

Thank you for applying to the East Bay Men's Recovery Program. Someone will reach out to you within 24 hours.

There was an error. Please try again later.

415 West 6th Street
Antioch, Ca 94509

info@ebmrc.net

1.800.418.6139

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