04. Resident Application for Admission

Resident Application -Home Intake


Welcome to the On Our Way Home intake wizard
Click next to begin!

General

Tell us about yourself

What is your chosen first name?
Client first name
What is your chosen middle name? No middle name? Move on to the next question.
Client middle name
What is your chosen last name?
Client last name
When is your birthdate?
Client birthdate
What are your chosen pronouns?Text field
What is your Social Security Number?
Text field
What is your race/ethnicity?
Client race
What is your gender identity?
Client gender
What is your marital status?
Client marital status
 What are the names and ages of your children?
Text field
If they are not living with you, who has custody?
Text field
What are your spiritual beliefs?
Dropdown

Contact Information

How can we reach you?

What is your email address?
Client email
At what phone number may we best reach you?
Client phone
What is your home 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 in the past 48 hours?

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?Text field
 

Occupancy

 

At what facility would you like to stay?
Text field
On what date would you like to be admitted?
Date
Do you have an active smart phone?Radio buttons

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
My previous tax year address:Text field
 
Certification
 
I certify that my answers are true and complete to the best of my knowledge. I hereby authorize a criminal background check to be initiated.
 
I understand that this is an application and does not constitute a rental agreement in whole or in part.  Furthermore I am:
• Ready to commit to living in an illicit drug and alcohol-free living environment.
• Ready to commit to helping and being accountable with others.
• Ready to commit to living as a functionally equivalent family.
• Ready to engage in resident driven recovery planning.
• Ready to abide by all safety guidelines, including COVID-19 guidelines.
• Understanding of services you do not offer.

If this application leads to tenancy, I understand that false or misleading information in my application or interview may result in my release.
 
Signature of Applicant: Signature