New New Student Application

Pacific Clinics Recovery Education Institute

pcrei

New Student Application

Please Note

Students are only required to fill out this application once. If you are a current student, please call 714-244-4322 to contact your Academic Advisor.

Before you proceed, you must meet the following eligibility requirements to participate in REI programs:

18+ years old

Yes No Not Selected

Orange County Resident

Yes No Not Selected

Identify as one or both of the following:

Consumer/Client/Member

Yes No Not Selected
Means I have lived experience with mental health and or substance use disorder/addiction

Family Member of Consumer/Client/Member

Yes No Not Selected
Means I have a family member who has experience with mental health and or substance use disorder/addiction

____________________________________________

General Information

First Name

Middle Name

Last Name

Street

City

State/Province

Zip/Postcode

Home Phone

Cell Phone

Birth Date

General Inquires

____________________________________________

Please indicate what programs you are interested in (Checkboxes – Choose all that apply:

Interested in:

General Wellness Workshops

Pre-vocation Workshop (Employment Training)

Employment Support

College Courses: Mental Health Worker Certification

College Courses: Drug & Alcohol Counseling Certification

College Courses: Human Services Generalist Certification

College Courses: General Education/Transfer

Peer Support Specialist Training

Tutoring

Enter the above code

Required