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
With regards to your Birth Certificate: Do you have access to
Dropdown
What are your chosen pronouns?
Text field
What is your Social Security Number?
Text field
Do you have your Social Security Card with you?
Dropdown
Have you ever served on active duty in the US Armed Forces, Reserves or National Guard?
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 your spiritual beliefs?
Dropdown
 
What is the status of your Drivers License?
 Dropdown
If revoked or suspended, when are you eligible to reapply or renewDate
 
State Identification Card
Dropdown
Are you currently involved in Drug Court
Dropdown
Do you have a High School Diploma or GED?
Dropdown
 
Tell us about your education history
EducationHistory
List the following Probation/Parole Information
 
Probation
 in what county?Text field
 

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

List at least one safe person that we can reach out to in case of a medical or behavioral emergency.  This person should be willing to assist in getting the emergency help that you might need.
 Contact
Contact mail addressText field
 
 
List your children and their ages
 
Family Members
 
 

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?
Client Referred By
 

Occupancy

 
At what facility would you like to stay?Client facility

On what date would you like to be admitted?   Client admit date    
 
What will you need assistance with in the first days of residence?  Dropdown
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