Application

 

THE INN RECOVERY COMMUNITY

Sober Homes Intake

Welcome to the Sober Homes intake wizard
Click next to begin!

General

Tell us about yourself
Are you applying for Dallas or Corsicana?
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What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
What is your prefered name?
Client nickname
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your gender?
Client gender
What is your marital status?
Client marital status
If you are married, are you needing couples/small family housing?
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Are you a veteran?
Client veteran
Are you pregnant? If so, what is your due date?
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Do you have live in children or children that would be visiting you? If yes, please list their names and ages.
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What is your sobriety date? If you do not have one yet please write "Active Addiction"
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If you have a sponsor: What is their name and phone number? Write "none" if you do not have a sponsor at the moment
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What is your SSN?
SSN
What is your highest level of education?
EducationHistory
If you are in school now, what school are you in?
Client school
Are you employed?
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Are you reciving SSI/SSDI?
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Are you applying while in a treatment center? If yes, what is the name of the place and your discharge date?
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Are you applying while on probation? If so, what county?
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Have you been arrested or in jail/prison at all in your life?
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Contact Information

How can we reach you?
What is your email address? (Please list your email where we can reach you right now)
Client email
If you are in a facility without access to your email, please list your email address you will have access to when you discharge:
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At what phone number can we best reach you at?
Client phone
Street Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip

Contacts

Give us a few people that we can reach out to in case of an emergency.
Contact

Insurance

Enter your insurance provider(s).
Insurance

Medical History

Tell us about your medical history.
When was your last relapse date?
Recovery history 1 relapse date
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice

Have you been clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
What allergies do you have? No allergies? Move on to the next question.
Client allergies

Have you had any of the following tests?

Medical Tests
 

Medications

List the medications you are currently prescribed.
Medication

Treatment Centers

Tell us about any treatment centers you've previously been admitted into.
TreatmentCenterHistory

Client Referral Source

 
Who referred you to us?
Client Referred By

Background

 
What would be on your criminal background check?
Criminal History
Are you currently on probation/parole? If yes, what county?
Probation
Do you give Shepherd Inn Transitional Housing permission to run your background?
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Sober Living History

Tell us about any sober livings you've previously been admitted into.
SoberLivingHistory

Employment

Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"
EmploymentHistory

Living Arrangement

Tell us about your living arrangement prior to moving into this facility
LivingArrangementHistory
 
Signature: Signature
 
DISCLAIMER:
 
I agree that everything I have answered has been truthful to the best of my knowledge. 

By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.