1 Application Form

IVY Home Foundation Application

Welcome to the IVY Home Foundation intake wizard. Thank you for taking the time to complete these forms. We want to learn more about you. These questions and the interview to follow help us know if we would be a good match for each other.
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
Birthdate
Client birthdate
Race/Ethnicity?
Client race
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? 
(We understand your current location may be a shelter, couch, or other. Please put your personal information in this area. Put the phone number of your Case Manager, Mentor, or Parole Officer in "Contacts" or "Client Referral".
What is your email address?
Client email
What phone number can we best reach you at?
Client phone
Street Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip
Driver's License, State ID, or Prison ID:
SSN

Contacts

Emergency Contact
Therapist/Clinician
Family Members
Text field

Insurance

Enter your insurance provider(s).
Insurance

Medical History

Tell us about your medical history. (Some of these questions may not apply to you. Put NA if it does not apply.)
When was your last relapse date (or what is your recovery 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
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
 

Treatment or Detention Centers

Tell us about any treatment or detention centers you've previously been admitted into.
TreatmentCenterHistory
 
Do you have active warrants?
Dropdown

Client Referral Source

 Who referred you to us?
Client Referred By
Text field
 
Who is your Case Manager / Mentor / Counselor / Sponsor / Parole Officer? (Incl. all contact info possible. It's important we connect.)
Client sponsor
Text field
 

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 applying to this facility
LivingArrangementHistory

Recovery History

Tell us about your Recovery History.

Inpatient or Outpatient therapy. Counseling. NA, AA, CR. Bible Study.

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Thank you for your submission. We will contact you within a few days.

If you haven't received a phone call from us within 3 days there's a chance we got distracted with the daily work. Call or email Ivery to see if your application was reviewed. iverykaufman@gmail.com  l  316.462.9948