APPLICATION:

General

If you are currently experiencing a psychiatric or medical emergency, please call 911 or visit your local emergency room. 

First Name: Client first name 

Middle Name: Client middle name 

Last Name: Client last name

Address: Client Address

City: Client City State: Client State Zip: Client Zip

Email: Client email Phone Number: Client phone

Gender: Client gender Birthdate: Client birthdate

School: Client school

Marital status: Client marital status

Race: Client race

Veteran: Client veteran

 

Desired Move in Date: Date

What is your sober date: Client sobriety date

 

Please list a few activities or hobbies you enjoy doing: Paragraph

Do you have any concerns about living with roommates: Checkboxes

If Yes, please explain: Paragraph

Do you currently work, go to school, or volunteer? Checkboxes

If Yes, please provide information about Name, Where, Your schedule, etc. If No, please provide information about your current situation:

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Emergency Contact

Family Members

Contact

Medical History

Diagnosis: Client diagnosis Health problems: Client health problems

Do you have any special medical equipment you would need to bring with you?

Checkboxes

If yes, please provide details: Paragraph 

Medications: Medication

Are you currently in a treatment program for substance abuse or behavioral health? Checkboxes

If Yes, please provide details of your program below -

Name of Program: Text field

Case Manager, Counselor, or Therapist Name: Text field

Case Manager, Counselor, or Therapist Contact Information: Therapist/Clinician

Condition being treated for: Text field

Please be advised: 

Acceptable and properly prescribed medication, like MAT (medication assisted treatment) prescriptions are permitted on the premise of Lemonade Recovery Homes. Lemonade Recovery Homes is not a medical facility and in accordance with the State of California regulations will not administer any medication to residents of Lemonade Recovery Homes.

All residents are responsible for the proper storage and self- administration of their own medication(s). 

Accessability

Can you walk independently? Checkboxes

If no or sometimes, please explain: Paragraph

Can you bath and dress yourself? Checkboxes

If No or Sometimes Explain:Paragraph

Do you have any issues with bladder control? Checkboxes

If Yes or Sometimes Explain: Paragraph

 

All applicants must be able to engage independently in major life activities including eating, dressing, bathing and other activities consistent with independent living. Please describe any concerns you may have regarding independent living, if applicable.

Paragraph

 

History of Substance Use

Substance of Choice: Client substances of choice

Kinds of meetings attended: Client kinds of meetings attended

Number of meetings attended each week: Text field

Allergies: Client allergies Relapse Date: Client relapse date

Referral source:

 Client Referred By

Licence number Text field SSN#Text field

Other History

Do you have a criminal record? Criminal History

Are you on probation? Probation

Insurance Information:

Health Insurance: 

Checkboxes

Health Insurance Policy

Provider: Client insurance provider Insurance Plan: Client insurance plan

Group ID: Client insurance group ID Policy#: Client insurance policy #

Address:(Street) (City) (State) (Zip) Text field

 Financial Information

Are you receiving welfare, unemployment compensation, disability payments, workman’s comp, alimony, VA benefits, or other income?

Checkboxes

Explain: Paragraph

 

Intake Coordinator notes:

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