Grandmaison Recovery Application
Welcome to the Grandmaison Recovery Application Process!
Please fill out all fields to guarantee your application is received.
Click next to begin!
General
Tell us about yourself
What is your first name?
Client first name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
Email Address?
Client email
Phone Number?
Client phone
Emergency Contact?
Contact
What is your relationship status?
Text field
Children? If yes, please share your situation.
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Have you been a resident of Grandmaison in the past?
Text field
Why did you choose to apply to Grandmaison?
Paragraph
Medical History
Tell us about your medical history.
Sobriety Date?
Text field
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
History of Self-Harm?
Checkboxes
Recent suicidal ideation?
Text field
Medications
Referral Source
Who referred you to us?
Client Referred By
If not listed, enter below:
Text field
Referral email?
Text field
Referral phone?
Text field
Occupancy
Anticipated discharge date?
Date
Have you ever been arrested, convicted, or questioned for arson or any violent or sexual crimes?
Checkboxes
Do you have any outstanding warrants?
Checkboxes
Any legal issues?
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Are you on Probation or Parole?
Checkboxes
If yes, complete below:
Probation
Do you have a valid license?
Checkboxes
Do you have a vehicle?
Checkboxes
Sober Living History
If you are unemployed, please share your work experience or a plan for future employment.
Thank you for submitting your application.
If you are experiencing issues with submitting, please ensure that all fields are completed.