Lafayette House Member Application
Welcome to the Lafayette House member application
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
What are your pronouns?
Client pronoun
When is your birthdate?
Client birthdate
What is your gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran
 

Criminal Background

Are you on Drug Court?

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Have you ever been convicted of rape, murder, or arson?

Checkboxes
 

Contact Information

How can we reach you?
What is your email address?
Client email
At what phone number where you can be reached?
Client phone
Street Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip
 
 
Family Members

Contacts

Give us a few people that we can reach out to in case of an emergency.
Contact

 

Medical History

Tell us about your medical history.
When was your last relapse date?
Recovery history 1 relapse date
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Text field
Are you currently taking suboxone, methadone, or any other MAT?
Checkboxes
If on MAT, which medication?
Text field
Have you been clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
What allergies do you have? No allergies? Move on to the next question.
Client allergies
 
 

Medications

List the medications you are currently prescribed.
Medication

Treatment 

If you are in a treatment center and don't have access to a phone, please let me know where. 
Name of treatment center Text field
Phone number of treatment center Text field
Counselor's name Text field

Client Referral Source

 
Who referred you to us?
Client Referred By

Occupancy

 
What facility will you be staying at?
Client facility
What date will you be admitted on?
Client admit date
What is the estimated length of stay?
Client estimated length of stay
When will you be discharged?
Client discharge date

Sober Living History

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

Employment & Education

Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"
EmploymentHistory
 
EducationHistory
 

Payment & Upfront Costs

To reserve a bed you understand that there is a non-refundable $200 membership/deposit fee. In addition, the first month's fee of $700 is required. 

An invoice will be sent to you upon completion of this application unless other arrangements have been made. 

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