What is your first name? 

Client first name

What is your middle name? (If no middle name, skip this question)

Client middle name

What is your last name?

Client last name

What is your birth date?

 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 veteran?

Client veteran status

Do you have any criminal history?

Radio buttons

 Are you currently involved with the Criminal Justice System?

Radio buttons

Are you currently on Drug Court or under any other Court Requirements?

Radio buttons

What is your email address?

Client email

At what phone number can we best reach you?

Client phone

Home street address?

Client Address

City

Client City

State

Client State

Zipcode

Client Zip

Give us a few people we can reach out to in case of an emergency. Include name, phone number, and relationship (Must list 2 people)

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Do you give consent to contact the persons listed as emergency contact?

Radio buttons

Please give us your insurance information. (must include: name, policy number, group, plan, and phone number)

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Do you consent to sharing your recovery history?

Radio buttons

What is your sobriety date?

Date

What is your relapse date?

Date

What is your substance(s) of choice?

Client substances of choice

Have you been clinically diagnosed with anything?

Text field

Do you have any health issues?

Text field

What kind of meetings do you attend?

Client kinds of meetings attended

What allergies do you have? (If none, list none)

Client allergies

Are you currently taking any medications?

Radio buttons

Do you consent to sharing medication information?

Radio buttons

Medication #1(list dosage, quantity, frequency, MD, start date or discontinued date)

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Medication #2(list dosage, quantity, frequency, MD, start date or discontinued date)

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 If other medication, list here with (list dosage, quantity, frequency, MD, start date or discontinued date)

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Do you consent to sharing treatment center history?

Radio buttons

Treatment Center Name

Text field

Address

Text field

When did you start with the treatment facility?

Date

When did treatment end?

Date

Treatment Type

Radio buttons

Reason for discharge

Radio buttons

If more than one treatment center, list all other centers here

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Who referred you to us?

Text field

Do you give consent to share with us any Sober Livings you have been admitted to?

 Radio buttons  

Please list the Sober Living history here. include name and address

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What was your estimated length of stay?

Text field

Reason for discharge

 Radio buttons

Do you consent to sharing your employment history?

Radio buttons

 

If currently employed, list employer name, address, contact information, and phone number. (if unemployed, leave empty)

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To reserve a bed, you understand and consent that a non-refundable deposit and the first month's dues are required.

Radio buttons

Tell us about your living arrangement prior to moving into Legacy Landing. (Where do you live now?)

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Start Date: Date

End Date: Date

Any other information we need to know?

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