Online Application Form

We welcome and encourage anyone to apply. We review each application on its own merits, and we offer residency on a space-available basis. Please fill out what you can and leave the rest blank. Confidentiality will be observed. We will not disclose information to anyone other than Gray Wolf Ranch admission staff. Your application will be reviewed within 24 hours and we will contact you by phone. If you have further questions or comments, please contact Gray Wolf Ranch.

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Personal Data Date Last Name: * First Name: * Date of Birth: * E-Mail Address: * Phone Number: * (xxx-xxx-xxxx)

Parent and Family Information

Mother Mother's First Name Mother's Last Name Mother's Address Mother' Home Phone Number Mother's Work Phone Number

Father Father's First Name Father's Last Name Father's Address Father's Home Phone Number Father's Work Phone Number

Siblings Siblings' Names

Medical Psychological Psychiatric Profile Any Current Medical/Psych. Problems? Any Physical Contraints? Current Medications Any Allergies or Current Problems? Height/Weight Do You Have Any Trek Experience?

Prior Treatment Were You Ever in Treatment? If So, Where? Who Was Your Counselor? How Did You Do?

Chemical Use What Was Your Drug of Choice? When Did You Last Use? How Often Did You Use? How Much Did You Use?

Education School History Are You in School Now? Do You Want to Continue While At Gray Wolf Ranch?

Employment Interests/Work History Do You Have Current Legal Obligations?

Life at Gray Wolf Ranch Are You Ready to Participate in Unsupervised Time in Treatment? Have You Attended AA/NA in the Past? Do You Have a Sponsor? Attitude Toward 12 step Groups Attitude Toward Volunteer Work

Best Time to Reach You