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NHMRC Application, downloadable


For those unable to download WORD doc above, here's a plain text form that you can "print screen" or possibly answer over the phone.

New Heartland Men's Recovery Center Application

Name ___________________________________

E-mail _________________________________

Age____  D.O.B. _____________ 

Marital status M__ D__ W__ Sep___ Single (never married)___ Engaged ___

Phone(s) ______________     ______________________

What is your desire for coming to this program?  _______________________________________



Are you currently abusing drugs?  Yes ___ No ___ if so, D.O.C? __________________

Do you drink alcohol regularly? Yes___ No __ Recent alcohol-related issues? Y__ No___

Have you ever attended a residential drug or alcohol facility? Y__  N __  Need detox? Y__  N__

Do you have any pending legal matters at this time? Y___ N___ ( if so, details on separate sheet)

Do you have any up-coming court dates? Y___ N___  (itemize separately, please, if so)

Have you ever been charged with any arson or sexual offenses against another person?  Y___ N__.

Do you have any child endangerment or abuse charges or allegations? Y___ N___.

Do you have any dental, medical, dietary or mobility special needs? Y___ N___.

Are you taking any prescription medications? Y___ N___ (if so, please list separately)

Have you ever received any form of mental health treatment? Y___ N___

Are you currently under the care of a Mental Health provider (psychiatrist, m/h counselor) Y___ N __

Do you have children? Y___ N___  (please prepare a list with age, sex, and whether you have custody of each)

Have your children ever been involved with CPS?  Y__ N___.

There are no pass/fail answers to the above. If you were perfect in every regard, it wouldn't be reasonable to apply.  So please answer truthfully so that you don't have to explain discrepancies later.

You may print and mail this to: New Heartland, attn Admissions, P.O. Box 643, Sherburne NY 13460

or Fax to New Heartland: (607) 674-4499

or send as an e-mail attachment to:

or it may be possible to review this over the phone with Admissions: (607) 674-4400.

For questions, or if no response, contact Executive Director Robert Klock (607) 343-5112 or

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