Application

Pine Street Recovery Homes Application 

Welcome to the Pine Street Recoverty Homes Intake
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 is your age?
Text field
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
Are you on MAT? If so, what MAT are you taking?
Text field
Do you have any pets? ESA? Service animal?
Text field
Do you have a vehicle? If yes, What is your license plate #?
Text field
If you do have a vehicle, is the vehicle insured?
Text field
Do you have a license to drive?
Text field
What is your license #?
Text field
Is the car registered?
Text field
 

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
Do you have a safe place to stay tonight?
Text field
Are you currently homeless?
Text field
How long have you been homeless?
Text field
Have you ever been homeless before? If so, how long?
Text field
Current living situation Street Address(Write NA for next questions if you are currently homeless):
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip
 
Are you on Parole or Probation?
Probation
Name of parole or probation officer
Text field
Phone number of parole or probation officer
Text field
Email of parole or probation officer
Text field

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 drugs have you used before?
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How long have you been sober?
Text field
What is the longest amount of time you have ever been sober?
Text field
What types of recovery have you tried before?
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What does your recovery look like today?
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When was your last relapse date?
RecoveryHistory
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
Have you ever been diagnosed with schizophrenia or Bi-polar? Are you taking medications for Schizophrenia or Bi-polar? Are you stabilized on your medication?(write NA if this does not apply to you)
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Are you on any narcotic medications?
Text field
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

Have you had any of the following tests?

Medical Tests
 

Medications

List the medications you are currently prescribed.
Medication

Treatment Centers

Tell us about any treatment centers you've previously been admitted into.
TreatmentCenterHistory

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.
SoberLivingHistory

Employment

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

Living Arrangement

Tell us about your living arrangement prior to moving into this facility
LivingArrangementHistory
Do you have a DV case?
Text field
Do you have any children? (If you do not have any children, write NA for all questions regarding children)
Text field
Are you in the process of getting parenting time or custody?
Text field
How many children do you have living with you?
Text field
Do you have a DHS or CPS case?
Radio buttons
 
Child Welfare History
 
Is there anyone restricted from being around you or your child?
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