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New Provider Registration
info@youngpathrecovery.org
2026-06-16T16:47:31+00:00
Provider Registration Form
"
*
" indicates required fields
Name
This field is for validation purposes and should be left unchanged.
Provider Name
*
Primary Contact Name
*
Internal Contact Email
*
For internal communication with YoungPath only. Email is not posted publicly on the website.
Public Phone Number
*
Internal Phone Number
*
For YoungPath to contact you only.
Website or Social Media Link
*
Provider Overview
*
Provide a brief summary of your organization, who you serve, and what makes your program unique (250 characters max).
Logo
*
Max. file size: 512 MB.
Scholarships Available
*
Yes
No
Level of Structure
*
Peer-supported/independent
Highly structured
Moderately structured
Relapse Policy
*
Zero tolerance
Case-by-case review
Step-down/reset process
Intake Process
*
Please select all items that apply to your intake process.
Phone Screening
Online Inquiry Form
In-Person Interview
Virtual Interview
Background Check
Drug / Alcohol Screening
Proof of Income Required
Government ID Required
House Tour Required
Deposit Required to Hold Bed
Same-Day Move-In Possible
Approval Within 24 Hours
Family Call Allowed During Intake
Probation / Case Manager Coordination
Move-In Orientation Required
Other
Intake Process Other Details
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