LIVE AND RECOVER, LLC

Application 

 

General Information 

First Name: Client first name

Middle Name: Client middle name

Last Name: Client last name

Date of Birth: Client birthdate

Age: Text field

Mobile Number: Client phone

Email: Client email

Driver's License (State and Number): Text field

Gender: 

Client gender

Marital Status: 

Client marital status

Children: 

Radio buttons

If so, please list below: 

Family Members

Emergency Contact

Contact

Treatment Experience

Are you currently in treatment? 

Radio buttons

If so, list where. If not, list last two facilities

TreatmentCenterHistory

Sober/Clean Date: 

Date

Clinician Name: 

Therapist/Clinician

Recovery Experience

Have you ever attempted recovery? 

Radio buttons

If so, please explain your recovery history, including past successes and challenges to maintain recovery (Failure DOES NOT disqualify you from residency)

Paragraph

Have you ever lived in Sober Housing? 

Radio buttons

If so, where? 

SoberLivingHistory

Reasons for leaving:

Paragraph

What does actively seeking recovery mean to you?

Paragraph

Employment

Are you employed? 

Radio buttons

If so, who is your employer?

EmploymentHistory

If not, what job plans do you have? Text field

What is your current income? Text field

If not self, who will be responsible for paying your residential fees and living expenses?

Name/Relationship: Text field

Telephone Number: Text field

Email Address: Text field

Education

Are you in school?

Radio buttons

What's your highest level of education completed?

Text field

Are you interested in: 

Checkboxes

Legal Entanglements

Do you have any current legal issues? 

Radio buttons

If so, what are you charged with? Text field

Are you on parole or probation? 

Radio buttons

If so, what are/were you convicted of? Text field

Are you a convicted felon? 

Radio buttons

If so, what were you convicted of and in what year were you convicted? Text field

Are you currently or have you ever been on the sex offender registry? 

Radio buttons

Medical

Do you have a medical doctor? 

Radio buttons

Name: Text field

Facility: Text field

Telephone Number: Text field

If applicable, please list past and/or current medical conditions: 

Client health problems

Are you vaccinated for COVID-19?

Radio buttons

Can you provide the vaccination card? 

Radio buttons

Are you ambulatory? Text field

Mental Health

Have you ever been diagnosed with or treated for a mental health disorder? 

Radio buttons

If applicable, please list all past and/or current diagnosis: 

Client diagnosis

Do you have a mental health medication provider? 

Radio buttons

Provider's Name: Text field

Facility: Text field

Telephone Number: Text field

Do you have a mental health counselor? 

Radio buttons

Counselor's Name: Text field

Facility: Text field

Telephone Number: Text field

If applicable, please list all past and/or current mental health treatment history: 

Paragraph

Current Medication List

Please list psychiatric medications first. 

Medication

Are you taking all medications as prescribed? 

Radio buttons

Allergies: 

Client allergies

 

Signature: Signature

Date: Date