Recovery Camp Application

CHUGACHMIUT RECOVERY CAMP APPLICATION
Llangarwik - "A Place of Awakening"

Welcome. Llangarwik is a recovery program focused on healing, personal growth, and building supportive relationships. Camp participants engage in daily group activities, learning experiences, meals together, and structured recovery work with support from trained counselors.
Full Name:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Age:
Gender:
Home Phone:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
Physical Address:
Mailing Address:
Emergency Contact Name:
Relationship:
Phone:
Format: (000) 000-0000.
Referral Source:
Briefly describe why you are interested in attending camp:
Do you currently struggle with substance use? If yes briefly explain:
Substances used:
Age at first use:
Any legal concerns we should know about?
Any health concerns we should know about?
Any allergy concerns we should know about?
Physical limitations where accommodation may be needed:
Any other concerns or scheduling issues that may impact participation?
After this application is reviewed, a counselor will contact you to schedule an assessment and intake.
Should be Empty:

CHUGACHMIUT RECOVERY CAMP APPLICATION