1. First Name
Client first name
2. Last Name
Client last name
3. Birth Date
Client birthdate
4. Phone Number
Client phone
5. Email
Client email
6. Street Address
Client Address
7. City
Client City
9. State
Client State
10. Zip Code
Client Zip
11. Drug of Choice
Client substances of choice
12. Sobriety Date
Date
13. Do You Have Two (2) Forms of ID?
Checkboxes
14. What Forms of ID Do You Have?
Dropdown
Dropdown
15. Do You Have a High School Diploma or GED?
Checkboxes
16. How Were You Referred to Us?
Dropdown
17. Are You Recieveing Social Security Benefits or Any Other Assistance?
Dropdown
18. Reincarnation Cottages Requires You to Work a Full Time Job as Part of Our Program. Are You Willing to Work Full Time?
Dropdown
19. Is There Any Reason Why You Wouldn't be Able to Work a full Time Job?
Text field
20. What Trade Are You Skilled In?
Text field
21. Do You Have Any Court Appearence's in The Next 12 Months?
Dropdown
22. Do You Have Any fines That You Are Paying or Need to be Paid?
Dropdown
23. Are You a Parent?
Dropdown
24. Have You Ever Been Convicted of a Felony or Misdemeanor Other Than Traffic Offenses?
Dropdown
25. Are You Willing to Have a Criminal Background Check Performed?
Dropdown
26. Are You Willing to be Regularly Drug Tested?
Dropdown
27. Are You Currntly Taking Any Medications?
Medication
28. Are You a Registered Sex Offender?
Dropdown
29. When Do You Expect to be Ready to Move In?
Date
30. Emergency Contact Information
Contact