May House Intake Application

May House Sober Living

Intake Application

Welcome to the May House intake wizard
Click next to begin!

General

Please tell us about yourself
Please note all items indicated with a * are required
What is your first name?*
Client first name
What is your last name?*
Client last name
What 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

Contact Information

How can we reach you?
Please note all items indicated with a * are required
What is your email address?*
Client email
At what phone number can we best reach you at?*
Client phone
What is your mailing address? (Please type N/A if you do not have one)*
Street Address:*
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip
 
Not including yourself, who else lives at this address? Please provide one name if possible.
Text field

Contacts

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

Insurance

Enter your insurance provider(s). This is for information only.
We do not bill insurance companies. 
Insurances

Medical History

Tell us about your medical history.
Please note all items indicated with a * are required
When was your last relapse date? Leave blank if you have never relapsed
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 type 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

Medications

List the medications you are currently prescribed.
Medication

Treatment Centers

Tell us about any treatment centers you've previously been admitted into.
Please note all items indicated with a * are required

Are you currenly in treatment?*
Text field

Please list your most recent and/or current Treatment Faclity.

TreatmentCenterHistory

Occupancy

 Please note all items indicated with a * are required
What facility will you be staying at?*
Client facility
What date will you want to be admitted on?*
Client admit date
What is the estimated length of stay?*
Client estimated length of stay

Sober Living History

Tell us about any sober livings you've previously been admitted into if possibly. List the most recent one if there are multiple. 
SoberLivingHistory

Employment & Education

Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"
Please note all items indicated with a * are required
Are you currently Employed or are in School?*
Dropdown

EmploymentHistory

EducationHistory

 Living Arrangement

Tell us about your living arrangement prior to moving into this facility. (Required)
LivingArrangementHistory
 
**Please go back and check previous required boxes are completed before continuing.**

What room type are you looking at?

Please note all items indicated with a * are required 

Please select what room type you are interested in:*

Dropdown

We are private pay, which means we do not bill insurance providers.

Do you have the ability to pay the on a weekly, bi-weekly, or monthly schedule?*

Dropdown

Current Recovery Status

Do you currently have a Sponsor?

Client sponsor

What step are you on with your current Sponsor?

Client step

Additional Notes

Please add any additional notes you would like to tell us about yourself?

Client notes

Relevant Background

We screen all applicants prior to admission and ask that you answer honestly. An answer of YES to the following questions does not immediately disqualify you. Please note all items indicated with a * are required.

Are you currenly on any Parole or Probation?*

Dropdown

If Yes, please complete below.

Probation

Have you had any child abuse convictions?*

Dropdown

If Yes, please provide breif detail and provide date(s). 

Paragraph

Are you a registered sex offender?*

Dropdown

Have you been convicted any violent crimes or arson?*

Dropdown

If Yes, please list and provide date(s).

Paragraph

**If you are unable to submit the application, please go back and check previous required boxes are completed before continuing.**