January 7, 2016


Good Samaritan Rehabilitation Application

Use this form to submit a confidential application for consideration for entry into the Good Samaritan rehabilitation residential treatment program. There will be in intake evaluation before you are accepted into the program. We value and respect your privacy, and as such Good Samaritan Rehabilitation will NEVER sell, transfer, or divulge your personal information to any third parties.

For a printable application, click here.