TomCat's Place Intake Form

 

Sober Homes Intake

Memorandum of Understanding 

What is the purpose of TomCat’s Place, LLC. Intake form? 

Client intake forms are preliminary paperwork to help establish  
if a person(s) is eligible for housing at TomCat’s Sober Living House.  
It does not mean that an individual is approved for housing.  

Once one of our team members reviews the Intake Form, our in-house counselor and/or CEO will contact the client directly, unless otherwise directed to speak to a case manager.  
 
Due to the sensitivity in nature of information requested, TomCat’s Place, LLC. will accept verbal approval from a client that gives permission to be able to communicate with a family member.  
 
TomCat’s Place, LLC., if applicable, will need to speak with your Case Manager(s), Clinician(s), Doctor(s) and/or Probation/Parole Officers. 
This process can take up to 24-48 hours (about 2 days).  
 
Listed below are the time limits for due process:  

- Time/date (e.g.  after the end of business day, weekend) of submitted form 
- Incorrect or missing information 
- Availability of a bed 

TomCat’s Place, LLC. is a resource for those who are interested in maintaining a sober life through independent living.  
 
Currently, we are unable to provide basic needs and we are not an emergency shelter and/or housing facility.  
 
Thank you,  
 
Catherine Caban-Cardona, CEO/Founder 
Thomas Cardona, COO/Founder 

Click next to begin!

General

Tell us about yourself
What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
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 status

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
Are you on probation or parole? 
Radio buttons
If yes, please fill out the below information, it is required to list officer name & number.
Probation

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.
I certify that I,Text field, take the medications listed at the frequency specified. 
 
Signature
 
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?
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"
Are you Employed? 
Radio buttons
If yes, please input job information below. 
EmploymentHistory

Living Arrangement

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