New Beginning Recovery House Application Form

 

Target Move In Date:Date

Which House You want to Move In:Text field

With New Beginning Before: Text field

Whos is paying for your bed fee? Text field

 Intial Application Notes:Text field

Basic Bio Information

Name:Client first nameClient middle name Client last name

DOB:Client birthdate

Phone:Client phone

Email: Client email

Emergency Contact: NameContact

Anniversary/Sobriety Date: Date

Driver License, yes or no: Text field    License Number:Text field

Car, yes or no: Text field,      Registerred & Insured? Text field

Insurance Company: Text field State:Client State

Identifications,Yes or no:Text field Which one?:Text field

Where in Treatment:Text field, Counselor:Text field

SponsorClient sponsor Case manager:Text field

How did you hear about us: Text field

Medical History

1.Have you ever been in any recovery house before, yes or no? Text field

  If yes, for how longText field

 If so, what was your experience was like? (Good or Bad) Text field

2. Are you in treatment currently, yes or no Text field

     If yes, please explain. Text field

     -Substance Abuse? Text field

     - Mental Illness? Text field

4. Current medication?  Text field

5. Is any of your meds psych meds, yes or no?Text field

6. Clean time in the past, yes or no, how long? Text field 

7.Primary Doctor? :Text field

Legal History

1. Have you ever been arrested? If yes, please explain. Text field

2. Do you have any pending case, yes or no?Text field

3. Probation or Parole, yes or no? Text field

4. Inmate Number: Text field,   Officer Name: Text field

5. Have you ever been convictd of sexual crime, yes or no? Text field

   If so, what is the charge and are you on registry? Text field

Employment & Personal Strength 

1. Are you currently employed? Text field

   If yes, employer name: Text field, your job: Text field

    how long you been working thereText field

   If no, last time employed: Text field, whereText field

    what did you do thereText field, for how long? Text field

 

2. What's your degree, trades or skills? Paragraph

3. Triggers to try & avoid? Paragraph

4. What do you enjoy as hobbies: Paragraph

Treatment Plan

1. Do you have a treatment plan?Paragraph

2. How can New Beginning help you? Paragraph