Intake Form

 

Unity Sober Living Homes Intake Form

Welcome to Unity Sober Living Homes!
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
What is your marital status?
Client marital status
Are you a veteran?
Client veteran status

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

Contacts

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

Insurance

Enter your insurance provider(s).
Insurance

Medical History

Tell us about your medical history.
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 clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any health issues (physical or not) that will inhibit your ability to perfrom in the program? 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

Client Referral Source

 
Who referred you to us?
Client Referred By
Referral source email address?
Text field

Occupancy

 
What house will you be staying at? If you have not been designated a house, leave blank. 
Text field

Employment

Tell us about your employment status. Are you able and willing to work? 
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Criminal History

Are you a registred sex offender?

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Do you have any outstanding warrants? 

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Are you currently on probation or parole?

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I hearby certify that the information above is true and accurate. Unity Sober Living Homes may utilize the information in rendering a decision on my acceptance into the program. Any act of dishonesty, or failure to disclose any pertient information can and will lead to discharge from the program. 

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Signature