Application for PorchLight

Application for PorchLight

Thank you for your interest in PorchLight! Please complete the following information so we can get to know you better, and help you on your journey to recovery. If you have any questions about this application, please feel free to email us at info@porchlightrecovery.com or call 833-799-6500 and someone can assist you through the process.

 

General

Tell us about yourself
What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran status

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

Emergency Contacts

Give us a few people that we can reach out to in case of an emergency.
Contact

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

What date will the you be beginning residency at PorchLight?
Client admit date
What is the estimated length of stay?
Client estimated length of stay
 

Employment

Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"
EmploymentHistory

 

 
Thank you for completing the application! Please sign and date the bottom to complete this form:
Signature
Date