Admission

If you are interested in participating in one of our treatment programs, please complete this request for information and we will contact you as soon as possible to continue our admission process.

Name:

Address:

City:  Province:  Postal Code:

Daytime Contact Number:  Alternate Contact Number:

Email Address:

Date of Birth:     I am a

I am interested in applying for the:

I have been referred to South Country Treatment Centre by: (leave blank if not applicable)

Additional Comments: