Hawaii Natural Drug Rehabilitation with Raw Detox & Psychotherapy psychotherapy, hydrotherapy             1-808-982-8202
Now is the time to Mind Your Body & Mend Your Mind     We are located on the powerful healing island of Hawaii
.  
 
 
.
 
 
REGISTRATION FORM / QUESTIONNAIRE
Fill in the following form, then click "SEND" at the bottom.
This will start the registration process.



Date
First Name
Last Name
EMAIL
Address
Phone (home)
Phone (cell)
Phone (office)
Age
Date of birth (year-month-day)
Sex
Weight (lb)
Height (inches)
No. of children & their ages


Addiction history & current habits
Drug of choice (legal or illegal)


List of prescription drugs taken
Other drugs
Coffee
Alcohol
Marijuana
White sugar


Health issues
Describe your diet (junk food, organic foods, meat, fish, vegetables?)
Sleep (average # of hours daily)
Sleep - quality
Sleep - falling asleep


Living situation
Employment
Other information of value


Security Code:
Please enter the 5 character code you see in the image to the left. - (NOTE: if it says HOLD, you have already submitted & must wait 60 min before it works again.)

Code:



BFN Secure Web Mail System





(NOTE: a copy of the form will be sent directly to you,
to the email address you gave.
NOTE: If you do NOT receive this copy-email - please contact us to confirm that it did reach us.)





To clear everything & start over


To return to the registration page - click here.

 

HAWAII NATURAL DRUG REHABILITATION
& RAW DETOXIFICATION RETREAT

Holistic Natural Residential Rehabilitation Programs
for freedom from addiction to legal and illegal substances - drawing from Naturopathic and Detoxification medicine, Behavioral and Psychodynamic therapy approaches, Meditation, Yoga and Spiritual practices
.
Note: We take only a small amount of clients, and our programs are individually designed. Our use of the ocean, the recreational activities & natural approaches facilitate recovery.
1-808-982-8202


ADDICTION RECOVERY
- COCAINE -
I had been doing drugs heavily for 16 years and no rehab or therapist could change me.
I was too full of toxins for the twelve-step program to ever work on me. I needed to clean my body out so that I could feel normal enough to fight the desire to do drugs.
Dr Baylac awakened me.
I have remained cocaine free now for 2 years (2008)....
More testimonials


Addiction program:


Dr. Baylac:


Keaau clinic:

Kapoho sanctuary:

Click to verify BBB accreditation and to see a BBB report.

  Get a life with dignity and purpose