Application

 Turning Point Recovery

Welcome to the Sober Homes intake wizard
Click next to begin!

General

Tell us about yourself
What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your gender?
Client gender
Height? Text field
Weight? Text field
What is your marital status?
Client marital status
Are you a veteran?
Client veteran
Do you identify as an individual with substance abuse disorder? Checkboxes
Please check all of the following forms of ID that you curently have in your possesion?
Birth certificate Checkboxes
State ID Checkboxes
SS card Checkboxes
Drivers LicenseCheckboxes
 

Legal information

Are you currently incarcerated? Checkboxes
If so when is your projected release date?Text field
Are you on probation or parole? If so what county and name of Officer?Text field
Please list everything you have been arrested for. Text field
Are you court ordered to sober living? Checkboxes
Do you have outstanding child support judgements? Checkboxes
Are you currently in a long term relationship?Checkboxes
If so is this person your spouse? Checkboxes
 

Contact Information

How can we reach you?
What is your email address?
Client email
At what phone number can we best reach you at?
Client phone
Street Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip

Medical Information

Tell us about your medical history.

When was your last date of use/drink Text field

What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Have you been diagnosed with any psychological/mental health disorders other than substance abuse including depression, anxiety, Bi-polor, schizophrenia? 
Text field
Do you have any health problems including back problems, hepatitis C, HIV, hernia? Text field
Are you able to get on a top bunkbed if that is all that is available? Checkboxes
Are you able to walk to a meeting if needed? Checkboxes
Are you on SSI or Disability? If so how much do your receive a month?Text field

Medications

List the medications you are currently prescribed.
Please list all current medications: Text field

 

Treatment Centers

Are you currently in treatment or IOP? 

If yes where? Text field

If in treatment what was your admission date?Text field

What is your discharge date? Text field

 

Client Referral Source

 Who referred you to us?
Client Referred By

 

Sober Living History

Tell us about any sober livings you've previously been admitted into.

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Employment

Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"
EmploymentHistory
 
Are you willing to take a job washing dishes? Checkboxes

 

 

Willingness

Are you in a longterm relationship? If so is this person your spouse? Text field 

What is their name? Text field How long have you been in this relationship? Text field

Are you willing to go a minimum of 30 days without talking with this person? Checkboxes

If not in a relationship are you willing to stay out of a realtionship for one year?Checkboxes

Are you willing to work all 12 steps with a sponsor before leaving Turning Point? Checkboxes

Are you willing to follow all suggestions of Turning Point?Checkboxes

Please write a few sentences about what you hope to gain from being a resident at Turning Point Recovery

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