About You
First Name: Resident first name
Middle Initial: Resident middle name
Last Name: Resident last name
Date of Application: Date
Desired Move In Date: Resident move in date
Birthdate: Resident birthdate
Phone: Resident phone
Email: Resident email
Street Address: Resident mailing address
About Your Addiction
Do you mainly need help with:
Checkboxes
If Other:
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What is your drug of choice: Resident substance of choice
Date of last use:Date
Substance used:Text field
Are you currently enrolled in a treatment facility?
Checkboxes
If yes, please complete the following:
Treatment Center: Treatment center 1 name
Started: Treatment center 1 started
Date of Expected Completion: Treatment center 1 ended
Notes: Treatment center 1 notes
Counselor's Name: Contact 1 name
Counselor's Phone: Contact 1 phone
Counselor's Email: Contact 1 email
Relationship: Contact 1 type
Are you considering, or have you been approved for,
any outpatient/aftercare treatment?
Checkboxes
If yes, where: Resident IOP
About Your Health
List any physical limitations:
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List any current medical concerns:
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List all prescriptions you currently take:
Medication: Medication 1 name
Reason: Medication 1 notes
Medication 2: Medication 2 name
Reason: Medication 2 notes
Medication 3: Medication 3 name
Reason: Medication 3 notes
Medication 4: Medication 4 name
Reason: Medication 4 notes
Is there anything else you’d like us to know about you?
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