Free Addiction Treatment for Women in Colorado

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Addiction Residential Treatment Program

Application

To apply for the CAYA Residential Treatment Program, please fill out the form below. Once we have received and reviewed your form we will be in touch.

First Name*
Last Name*
Email*
Phone Number*
SSN #*
Age*
Date of Birth*
Physical Address*
City*
State*
Zip Code*
What is your addiciton?*
How long have you been in addiction?*
Are you currently taking any prescription medications? If so, listen them.*
Do you have any upcoming court dates?*
- Yes
- No
If you entered yes, where are your court dates?
County*
State*
Are you currently on parole or probation?*
- Yes
- No
If you entered yes, where are your court dates?
County*
State*
Do you have any previous misdemeanor charges?*
- Yes
- No
If yes, please explain
Do you have any previous felony charges?*
- Yes
- No
If yes, please explain
Do you have any previous violent charges?*
- Yes
- No
If yes, please explain
Do you have any previous sexual abuse charges?*
- Yes
- No
If yes, please explain
Do you have any medical conditions?*
What is your spiritual history and/or views on God?*
By checking “yes”, I agree that I have answered all statements truthfully to the best of my ability.*
- Yes
- No

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