This form is a REQUEST. Filling out this form DOES NOT guarantee your request will be granted. Furthermore, failure to follow this plan will result in an immediate expulsion from 4th Dimension Sobriety programming and property.
IF RELAPSE HAPPENS DURING THIS TIME YOU WILL NOT BE GRANTED THE PRIVILEGE OF AN EMERGENCY REVIEW. IF YOU RELAPSE, PLEASE KINDLY COME BACK THE THE HOUSE AND PACK YOUR THINGS.