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Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Mobile Phone

Work Phone

Email*

Sobriety Date*

MM

DD

YYYY

I was referred to Harmony by (if applicable):

My aftercare plan/program is (if applicable):

Message

Consent*

Yes

I understand that by submitting this form I authorize Harmony Foundation to contact me for Harmony related purposes. I understand that this authorization is voluntary and that I can revoke it at any time through written notice sent to the Harmony Foundation.

Text Consent*

Yes

I understand that by submitting this form I authorize Harmony Foundation to contact me via text for Harmony related purposes. I understand that this authorization is voluntary and that I can revoke it at any time through written notice sent to the Harmony Foundation.

Community Connection Program

Yes! I want to help a new Harmony graduate

I understand that by selecting yes, I am authorizing Harmony Foundation to enroll me in the Community Connection Program for which I will be eligible after 1 year of continuous sobriety and regular participation in a 12-step program.

Private Alumni Facebook Page

Yes! Email me an invite

I understand that by selecting yes, I am authorizing Harmony Foundation to send me an invitation to a private, closed group, Facebook page designed to be an open forum of communication for Harmony Alumni only.

Hope Connection Program

Yes! I want to help

I understand that by selecting yes, I participated in the Hope Program at Harmony and am authorizing Harmony Foundation to enroll me in the Hope Connection Program for which I will be eligible after 6 months of continuous sobriety.

Email

This field is for validation purposes and should be left unchanged.

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