Admissions Application

If you think that you have a substance addiction and want help, take this first step towards recovery by filling out our application form. Someone from Jericho Road will contact you by phone to talk about your next steps.

If you believe your friend or family member is struggling with an addiction problem and you would like more information about Jericho Road, please contact our office or visit the community resources page for further help.


Name *
Please provide your legal names.
Phone *
We require a valid number to contact you.
What substances do you use? *
Please check all that apply.
Are you currently taking Methadone or Suboxone? *