Application

A Way Home Housing Application

 
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General

Tell us about yourself
What is your first name?
Client first name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your gender?
Client gender
What date would you like to admit on?
Client admit date
What is the estimated length of stay?
Client estimated length of stay

What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
Who referred you to us?
Text field

Contact Information

How can we reach you?
What is your email address?
Client email
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

Medical History

Tell us about your medical history.
When is your sobriety date?
Sobriety 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 allergies do you have? No allergies? Move on to the next question.
Client allergies
 

Medication: Medication

Treatment Centers

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

 

Sober Living History

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

Living Arrangement

Tell us about your living arrangement prior to moving into this facility
LivingArrangementHistory

Tell Us About Yourself

Help us to know you better. Why are you looking into getting into sober living? Why would you be an assett to our sober living community? 

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We Will Review Your Application. Thank You.