Grace Refuge Recovery Intake Packet

 

 

Sober Living Intake

Welcome to the Sober Homes intake wizard
Click next to begin!

General

Tell us about yourself
First name?
Client first name
Middle name? No middle name? Move on to the next question.
Client middle name
Last name?
Client last name
Birthdate?
Client birthdate
Race/ethnicity?
Client race
Gender?
Client gender
Marital status?
Client marital status
Are you a veteran?
Client veteran
Are you currently receiving any type of government assistance? ( Cash aid, food stamps, medi-cal) 
 Text field
Are you currently on parolle or probation? 
Text field
If yes, what is the contact information for your parolle or probation officer?
Text field phone: Text field
Do you have any domestic violence history?
Text field
Have you been convicted of any sexual offences?
Text field

Contact Information

How can we reach you?
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

Insurance

Enter your insurance provider(s).
Insurance

Medical History

Tell us about your medical history.
When was your last relapse date?
Recovery history 1 relapse date
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Have you 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
 

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

Occupancy

 
What facility will you be staying at?
Client facility
What date will the you be admitted on?
Client admit date
What is the estimated length of stay?
Client estimated length of stay
When will the you be discharged?
Client discharge date

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