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ON-LINE 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 GWR 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.
Date
Last Name:
First Name:
Date of Birth:
E-Mail Address:
PARENT AND FAMILY INFORMATION
Parents First Name
Mother
Father
Parents Last Name
Mother
Father
Address
Mother
Father
Home Phone Number
Mother
Father
Work Phone Number
Mother
Father
Siblings
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 GWR?
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

Gray Wolf Ranch, P.O. Box 102, Port Townsend, Washington 98368
Toll Free: 1-800-571-5505 Local: 360-385-5505 email: gwr@graywolfranch.com