Application

Malibu House of Recovery Application

Welcome to the Malibu House of Recovery Application wizard
Click next to begin!

General

Tell us about yourself
Todays Date?
Date
What is your first name?
Client first name
Do you have a nick name youd like us to call you? No nick name? Move on to the next question.
Client nickname
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
Do you have a License?
Radio buttons
Do you have a vehicle?
Radio buttons
Can you pass a drug test?
Radio buttons
 

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

Legal Sytem

Enter your probation/parole officers or case manangers or lawyers information.
Probation
Contact
What State and county are your legal issues out of?
Text field
Are you a Fellon?
Radio buttons
what are your charges?
Paragraph
Have you been sentenced on any of these cases?
Radio buttons
if yes and you are still serving any sentence waht is it? ie; 3 years probation or 1 year house arrest
Paragraph
Do you know your case number(s)? Please enter them below.
Paragraph

Medical History

Tell us about your medical history.
When was your last relapse date?
RecoveryHistory
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Have you ever 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 kind 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

Have you had any of the following tests?

Medical Tests
 Have you ever tested positive for HIV/AIDS?
Radio buttons
If Yes are you on medication or being treated?
Radio buttons
 

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
Name of person or entity that reffered? If you have their phone number please include it here
Text field

Occupancy

 What date would you like to move in on?
Date
 
 
How long do you think you will be staying with Malibu House?
Text field

Sober Living History

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

Employment

Tell us about your employment status and ability to pay rent. Rent cost $500 per month or can be billed weekly at $125 per week. 
If you're currently unemployed select "unemployed" under "type"
EmploymentHistory
 
Are you currently employed?
Radio buttons
If so where at or with who?
Text field
what is your weekly income?
Text field
Do you have any skills or trades? if so what are they?
Paragraph
 
How do you plan to support yourself while at Malibu House?
Paragraph
Are you able to pay anything upfront to move in or pay the $175 bed fee?
Radio buttons
If so how much can you afford?
Text field
If you can not afford anything to move in, this does not disqualify you from coming to Malibu House we do have a limited amount of scholarships we can offer qualifying canidates. If you feel you may need this please tell us why.
Paragraph
 
 

Living Arrangement

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