Welcome. Please complete the application form to be considered for admission.

Name: Client first nameClient last name

Phone Number: Client phone

Email:Client email

Most Recent Address: Client Address

Date of Birth: Client birthdate

Allergies: Client allergies

Race: Client race

Referred By: Client Referred By

Veteran Status: Client veteran status

Consent to Recieve Text Messages: Checkboxes

Recovery

 

Drug of Choice: Client substances of choice

Sober Date: Date

Recovery Program: TreatmentCenterHistory

Employment and Vehicle

 

Employment Status: EmploymentHistory

Financial Obligations: Text field

 

Insurance Information

   Provider:Insurances

 

Emergency Contact

 Contact

 

Legal History

Probation:Probation

Parole: Dropdown

Officer's Name: Text field

Officer's Number: Text field

Completion Date: Date

Open Cases: Text field

Criminal History: Text field

Sex Offender: Dropdown

Medications

List Current Prescribed Medications and Doses:

Medication