May House Intake Application

Intake

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

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

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

Insurance

Enter your insurance provider(s). This is for information only, we do not bill insurance. 
Insurance

Medical History

Tell us about your medical history.
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

Medications

List the medications you are currently prescribed.
Medication

Treatment Centers

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

 

Occupancy

What facility will you be staying at?
Client facility
What date will the you be admitted on?
Client admit date
What is the estimated length of stay?
Client estimated length of stay
We are Private Pay, which means we do not collect from medical or government entities. Do you have the ability to pay the housing fee on-time? 
Dropdown

Sober Living History

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

Employment

Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"
EmploymentHistory
 
Are you currently in School?
Dropdown
If yes, what school/program are you in? 
Client notes

Living Arrangement

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

Current Recovery Status

What is your sobriety/clean date?
RecoveryHistory
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
Do you have a Sponsor?
Client sponsor
If so, what step are you on?
Client step
 

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. All answers will be verified. 

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