Application

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New Member Application - Protected and Confidential 

First Name

Client first name

Last Name

Client last name 

Mailing Address

 Client Address

Email

Client email 

Phone #

Client phone  Birthdate Client birthdate 

Marital Status

Client marital status 

Race

Client race 

Sobriety Date 

Recovery history 1 sobriety date 

Todays Date 

Date 



EMPLOYMENT

Employment

Employer 1 name 

Job TitleCurrent 

Employment 1 position 

Wages

Employment 1 income 

Occupation

Employment 1 type 

Start Date

 Employment 1 started

End Date

Employment 1 ended 



IN CASE OF EMERGENCY

Name

Contact 1 name 

Phone

Contact 1 phone 

Type

Contact 1 type 

Email

Contact 1 email 



 

 

 

ADDICTION HISTORY  

Drugs abused in the last 3 years

 Paragraph

Explanation of duration of use

 Paragraph

Substance of Choice

 Client substances of choice



Health Insurance

Provider

 Client insurance provider

Insurance Plan

 Client insurance plan

Group Number

 Client insurance group ID

Policy #

 Client insurance policy #



MEDICAL HISTORY

Diagnoses

 Client diagnosis

Allergies

 Client allergies

Medical Devices

 Checkboxes

Psychiatric Diagnosis

 Client diagnosis

Hospital Stays

 Text field

Chronic Pain

 Checkboxes



MEDICATIONS  

Medication #1

Medication

 Medication 1 name

Dosage

 Medication 1 dosage

Quantity

 Medication 1 quantity

Category

 Medication 1 category

Frequency

 Medication 1 frequency

Prescribing Doctor

 Medication 1 md

Refills Left

 Text field

Notes

 Medication 1 notes

 

Medication#2

Medication

 Medication 2 name

Dosage

 Medication 2 dosage

Quantity

 Medication 2 quantity

Category

 Medication 2 category

Frequency

 Medication 2 frequency

Prescribing Doctor

 Medication 2 md

Refills Left

 Text field

Notes

 Medication 2 notes

 

Medication#3

Medication

 Medication 3 dosage

Dosage

Medication 3 dosage 

Quantity

Medication 3 quantity 

Category

 Medication 3 category

Frequency

 Medication 3 frequency

Prescribing Doctor

 Medication 3 md

Refills Left

Text field 

Notes

Medication 3 notes 



CLINICIANS  

Clinician #1

Name

Contact 1 name 

Phone

Contact 1 phone 

Type

Contact 1 type 

Email

Contact 1 email 

 

Clinician #2

Name 

Contact 1 name 

Phone

Contact 1 phone 

Type

Contact 1 type 

Email

Contact 1 email 

 

Clinician #3

Name

Contact 3 name 

Phone

Contact 3 phone 

Type

Contact 3 type 

Email

Contact 3 email 



SPONSOR/12-STEPS

Do you have a sponsor?

 Checkboxes

If not, would you like help finding one?

 Checkboxes

What step are you currently on?

 Client step  Fellowship association  Client kinds of meetings attended



PEER RECOVERY COACH/RECOVERY MANAGER

Are you working with a recovery coach?

 Checkboxes

If yes, Name?

 Medication 5 name

Phone #

 Contact 5 phone  Have you ever worked with a Recovery Coach in the past?  Checkboxes



LEGAL MATTERS

Are you currently undergoing any legal matters?

 Checkboxes

Are you currently enrolled in drug court?

 Checkboxes

Are you assigned a probation officer?

 Checkboxes

If yes, name & phone number

 Contact 6 name Contact 6 phone

Are you working with an attorney?

 Checkboxes

If yes, name & phone Number

 Contact 7 name Contact 7 phone

Notes/Details

 Paragraph    



MOST RECENT TREATMENT  PROGRAM

Referring Facility

Treatment center 1 name

Contact Name

Treatment center 1 notes

Date Started

Treatment center 1 started

Date Discharged

Treatment center 1 ended

Notes/Details

Treatment center 1 notes    



AFTERCARE PLAN

Outline your aftercare plan upon discharge

Paragraph



OTHER CONTACTS

Name

 Contact 4 name

Phone #

Contact 4 phone  Email Contact 4 email

Name

Contact 5 name 

Phone #

Contact 5 phone  Email Contact 5 email



FINANCIAL RESPONSIBILITY

Responsible party

 Client payment payer

Phone #

Contact 10 phone 

Payment Amount

 Client payment amount

Relation

Contact 10 type 

Frequency

Client payment frequency 

Email

Contact 10 email