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:

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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?

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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?

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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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