Surrendered Souls Application 
Today's Date: Date

Client Information

First Name: Client first name

Last Name: Client last name

Date of Birth: Date

Social Security Number: SSN

Sex: Client gender

Client Phone: Client phone

Client Email: Client email

Home Street Address (NO P.O. BOX): Client AddressClient CityClient StateClient Zip

Referral Source and Legal Information

Facility Name: Contact

Facility Contact Person: Contact

Client Insurance Info: (Include all that apply)Dropdown
Other: Text field

Policy Number: Text field

Group Number: Text field

Is this a legal referral? Checkboxes

Currently incarcerated? Checkboxes

Charges/Convictions (Past, current, and pending)

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Probation/Parole Officer Name: 

ProbationContact

Is the client required to be on the sex offender registry? Checkboxes

Probation/Parole End Date: Date

Restraining Order in Place? Checkboxes

Name of Other Person Involved: Text field

Referral Reason and Contact

Reason for Referral: 

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 Person Completing Form: 

Contact

Medical Follow-up/Prescriptions Given: 

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Any relatives/significant others at NAVA or Fox Recovery? Dropdown

Name of Related Person: Contact

Health & Risk Info
High Risk Categories (Include all that apply):
Checkboxes

Additional Information: 

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Internal Use Only
Location: Text field

Provider Information: 

Contact

Scheduled Appt. Date:DateNotes: Text field

Last Home Address: Client AddressClient CityClient StateClient Zip

Do you have Medicare? Checkboxes

Family Information
Marital Status: Client marital status

Spouse's Name: Contact

Number of Children: Number field

Emergency Contact:

Contact

Medical & Psychological History
Medical Problems (Include all that apply):

 Checkboxes

Psychological Diagnoses (Include all that apply):

 Checkboxes

Medications

Medication

Substance Use History
Do you have a problem with alcohol/drugs? Checkboxes

If yes, drug(s) of choice:Client substances of choice

Last Use Date: Date

Sobriety Date: Date

Relapse Date: Date

Programs Attended: TreatmentCenterHistorySoberLivingHistory

Education & Employment
Last Grade Completed: Dropdown

Jobs Held in Past Year: Number field

Short/Long-term Goals: 

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Religious Affiliation
Present Faith: Text field

Legal Information
Legal Status:
Checkboxes

Currently Incarcerated? Checkboxes

Facility Name & Address: Client facility

Projected Release Date: Date

Classification Officer Name: Text field

Phone #: Number field

Email: Text field

Outstanding Charges? Checkboxes

State & County of Charges: Text field

Offense History: 

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Personal Statement
Strengths, Weaknesses, Difficulties, etc.: 

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Affirmation
I am voluntarily applying to Fox Recovery. I authorize the release of the above information for the purpose of evaluation and potential admission. I certify that the information is true and complete. I understand that false information may lead to rejection or dismissal from the program.

Signature: 

Signature
Date: Date