Maddy's Place Application

Personal Information:

First name:

Client first name

Middle Name:

Client middle name

Last Name:

Client last name

Phone Number:

Client phone

Email Address:

Client email

Date of Birth:

Client birthdate

Driver's License/ID#:

Number field

Last 4 of SS#:

SSN

Marital Status:

Client marital status

Are you a Veteran? If so, what is your status?

Client veteran status

Do you have any children? If so, please list their names and ages.

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LivingArrangementHistory

What is your Criminal History?

Criminal History

Emergency Contact Information:

Who should be contacted in the case of an emergency?

Contact

Medical/Psychiatric History:

Please list your Insurance Information:

Insurances

Please list ANY Allergies.

Client allergies

Medications you take currently, dosage, when and how many times per day.

Client medical notes

Have you been clinically diagnosed with anything?

Client diagnosis

Have you had any medical tests given with results?

Medical Tests

Have you had any vaccines?

Vaccines

Any other medical information we need to know:

Client medical notes

Education History:

Did you graduate Highschool and/or have a GED?

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Have you attended college and/or have a degree of any kind?

EducationHistory

Employment History:

Please list your current employer. If none, please skip. 

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What is your monthly gross income?

Number field

Please list all employers you have had in the past 5 years:

EmploymentHistory

Substance Abuse History:

 What is your drug/substance of choice?

Client substances of choice

Sober Living and Treatment History:

 Please list your sober living and/or treatment center history:

SoberLivingHistory

Recovery History:

RecoveryHistory

Do you have a Sponsor/Recovery Coach? If so, list name and contact info.

Client sponsor

What kind of meetings do you attend and where?

Client kinds of meetings attended

Are you familiar with the 12 steps and if so, what step are you on?

Client step

Reason for entering sober living:

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Character References:

Please list at least 3 character references we can contact.

Name: Text field Phone Number: Text field

Name: Text field Phone Number: Text field

Name: Text field Phone Number: Text field 

Referral:

How did you hear about us?

Text field

Client Signature

Signature     

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.