Resident Application to Sober 4 Life Inc.: CJO House
Personal Information:
Applicants Name: Client first name Client last name
Desired move in date: Client admit date
Estimated Length of Stay: Client estimated length of stay
Phone: Client phone Email Address: Client email
Date of birth: Client birthdate Age: Text field
Social Security Number: SSN
Gender: Client gender Pronoun: Client pronoun
Marital Status: Client marital status
Race: Client race Ethnicity: Client ethnicity
Veteran: Client veteran status
Hometown Address: Client Address
Was Client Referred?: Client Referred By
Family Members/Emergency Contacts: Family Members
Other Contacts: Contact
Prior Living Experiences: LivingArrangementHistory
Sober Living History: SoberLivingHistory
Has Applicant ever lived in a sober house? Radio buttons
If yes, provide sober house names, dates and reason for leaving: Paragraph
Describe Applicant's most recent living location and situation: Paragraph
Applicant's Drug/Alcohol Use and Treatment:
Applicant's Drug of Choice: Client substances of choice
1st Drug of Choice: Text field
Method: Text field Age First Used: Text field Date of last use: Text field
2nd Drug of Choice: Text field
Method: Text field Age First Used: Text field Date of last use: Text field
If Applicant is currently in a Treatment Center, provide the name of the center, the start date, end date, approx discharge date:
Treatment Center History: TreatmentCenterHistory
Case Manager: Text field Case Manager Contact Info: Paragraph
What brought the Applicant to that Treatment Center? Paragraph
What was Applicant's longest clean time and when? Paragraph
Describe Applicant's Relapse History: Paragraph
Has Applicant ever overdosed? Radio buttons If yes, # of times: Text field Was Applicant hospitalized? Radio buttons
Provide any additional details regarding Applicant's overdose history: Paragraph
Provide and details regarding Applicant's participation in a recovery plan: Paragraph
Recovery History: RecoveryHistory
Step: Client step
Sponsor: Client sponsor
Kinds of Meetings Attended: Client kinds of meetings attended
Health Problems:Client health problems
Allergies: Client allergies
Applicant's Current and Past Medications:
Diagnosis: Client diagnosis
Medications: Medication
Has Applicant ever been on Maintenance Meds in the past? Radio buttons
If yes, describe what meds and when: Paragraph
Is Applicant currently on or plan to be on maintenance meds? Radio buttons If yes, provide names: Medication
Provide any details if Applicant plans to continue maintenance meds: Paragraph
Is Application on any other medications? Radio buttons
If yes, Applicant's provide all other Meds:
Medication
Education: EducationHistory
School: Client school
Therapist/Clinician: Therapist/Clinician
Applicant's Legal Matters:
Does Applicant have any outstanding Legal Matters? Radio buttons Describe: Paragraph
Does Applicant have a valid driver's license? Radio buttons If yes, provide State, License # and Expiration: Text field
Does Applicant plan on bringing a car? Radio buttons
Client's Insurance: Insurances
Applicant's Financial Information:
What Applicant's most recent or current occupation or job description: EmploymentHistory
Employment History: EmploymentHistory
What are Applicant's plans for employment while at our home: EmploymentHistory
Applicant's Anticipated amount of monthly income: Text field
Provide any additional means of Applicant's financial support: Paragraph
Name of Person Completing this Application: Text field
If other than the applicant, provide contact information: Text field
Signature: Signature
Today's Date: Date
By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.
For office use only:
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