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PLEASE NOTE:  All incoming clients are required to take a COVID-19 test before entering the program. We are more than willing to assist you in the process if needed. Please call us at 205-324-2271 if you have any questions about testing.

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Applicant Information:

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Last Address:
Email Address:*
*This email will be used for general contact needs and is where you will receive a copy of your completed application as well as any necessary follow-up information.

Emergency Contact Information:

Address

Additional Information:

Are you an alcoholic?
Are you a drug addict?
Do you have any warrants?
Have you ever been charged with a sexual offense or are you a registered sex offender?
Have you ever been charged with, or convicted of, a violent crime?