Request for Services (lead form)

Request for Services

 

Thank you for your interest in Racing for Recovery.  We offer a balanced holistic lifestyle of recovery to all persons affected by addiction.  We understand the devastation drugs and alcohol have on self, family and community
and are proud of you to taking ACTION to improve your life. 

Racing for Recovery offers an opportunity for those who are ready for an exciting, educational.
rewarding and beneficial concept to utilize a program which focuses on healing from emotional
trauma that lead to a choice to use drugs and alcohol.   

Referral Source: 

Client referral source

Referred by:

Client referred by

Have you received services from us in the past?

Radio buttons

Desired Date to Start Services: Date

What types of services would you like to recieve from us?

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General Contact Info:

First Name: Client first name

Last Name: Client last name

Address: Client Address

City: Client City

State: Client State

Zip: Client Zip

County: Text field

Email: Client email

Phone Number: Client phone

Birthdate: Client birthdate

Gender: Client gender

Marital Status: Client marital status

Do you have a photo ID?: Radio buttons

Do you have a current unrestricted driver’s license? Radio buttons

Are you currently employed? Radio buttons

 

Do you have Health insurance? Radio buttons

What kind of Health insurance do you have? 

Insurance Name: Radio buttons

*If your insurance company is not listed please fill in with your carrier: Text field

Insurance Policy Number: Text field

Insurance Group Number: Text field

Insurance Plan: Text field

*If you do not have the card on you and do not know the information above but know you have insurance, we will gladly retreive that information for you with your full Social Security Number: Text field

 

Recovery Information:

Substances of Choice: Client substances of choice

Sobriety Date: Recovery history 1 sobriety date

Are You Currently in Treatment? Radio buttons

Most Recent Treatment Center Name: Treatment center 1 name

Who is your Case Manager/ Social Worker? *insert first name, last name, contact informationText field

Treatment Admit Date? Treatment center 1 started

Treatment Discharge Date? Treatment center 1 ended

Reason for Discharge: Radio buttons

Are you fully Detoxed? Radio buttons

Where did you stay last night:Radio buttons

If in treatment or jail, do you have a safe sober place to stay when you leave? Radio buttons

Are you on any of the following MAT substances? Suboxone (other than detox), Methadone, Bunavil, Sublocade, Zubsolv, Vivitrol, etc. Radio buttons

*If you answered yes to being on a MAT substance please list what you are on. Text field

 

Criminal Background

Are you a registered sex offender?  Radio buttons

Do you have any outstanding warrants?  Radio buttons

Are you on probation? Radio buttons

If yes, what court(s)? Text field

Name of Probation Officer(s) Text field

Do you have any felony convictions?  Radio buttons

If yes, what? Text field

Do you have any pending sentencing or possible jail time upcoming?  Radio buttons

If yes, what is your court date? Date

Why, specifically, do you want to come to Racing for Recovery?

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Once your form is submitted, we will contact you for scheduling.

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.

I attest that the above information is correct and subject to further background review.

Electronic Signature

Signature