Application

 

Intensive Recovery Application

Welcome to the Sober Homes 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 Social Security Number
SSN
What is your gender?
Client gender
What is your marital status?
Client marital status
Does your spouse support your desire for recovery?
Text field
Do you have any children? If so, how many?
Text field
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 Contact 

Give us a few people that we can reach out to in case of an emergency.
Do you consent for us to communicate with the contacts below?
Dropdown
Contact

General Information 

 What is your drug of choice?
Text field
How long have you been using for?
Text field
Do you need to detox? 
Text field
 
Have you ever been incarcerated?
Dropdown
Are you out on bond, probation, or parole? If yes, please list the officer's contact information.
Paragraph
 

Medical History

Tell us about your medical history.
Have you been clinically diagnosed with any mental health disorders? 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
Do you have any disabilities that will prevent you from using a bunk bed?
Dropdown

Have you had any of the following tests?

Medical Tests
 

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?
Client Referred By

 Recovery Commitment 

 
What date are you looking to admit into the recovery program?
Date
Are you willing to make a 6-month commitment to this program?
Dropdown 
Do you agree to random drug tests?
Signature
If you have been in recovery before, what makes this time different?
Paragraph
 
 

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

Living Arrangement

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

 Here at 143 Ministries, we believe in relationships. To get to know you better, we ask that once you have completed this application, please call 1-800-560-7143 Katherine's Way (Female) Ext.1 Immanuel House (Male) Ext. 2.

We look forward to hearing from you and pursuing the recovery journey together.