Application / Intake Form

Starts With Love Foundation  

Application

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
Have you ever been known by an alternate name?
Text field
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your gender identity?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran
Social Security Number:
SSN
Driver's License or State Issued Identification Number or other Identification Card Number:
Text field
Who is completing this application?
Radio buttons
 

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
Street Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip
 
Do you consent to a background check?
Radio buttons

I agree to be contacted by Starts With Love Foundation-Saguaro House via SMS, email, or phone using the information I provided for the purposes of reviewing my application.
Checkboxes

Contacts

Give us a few people that we can reach out to in case of an emergency.
Contact

Insurance

Enter your insurance provider(s). This information will be utilized in case of a relapse so we can help find a detox facility for you. 
Insurance

Medical History

Tell us about your medical history.
When was your last relapse date?
Recovery history 1 relapse date
What is your substance(s) of choice? 
Client substances of choice
Have you been clinically diagnosed with anything? 
Client diagnosis
Do you have any health problems? 
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 

Do you have any issues ascending or descending stairs?
Radio buttons

Let us know if you have any mental health issues or diagnosis?
Text field

Do you have a history of self-harm?
Radio buttons

Medications

List the medications you are currently prescribed including the dosage.
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
 
All residents are required to seek employment, be enrolled in school at least part-time, or take part in volunteer work up to 32 hours per week.
What are you plans?
Checkboxes

Living Arrangement

Tell us about your living arrangement prior to moving into this facility
LivingArrangementHistory

Program Details

How will you pay for the program? Apple Pay, Zelle, and Cash are accepted.
Checkboxes

Do you have any concerns sharing a room?
Radio buttons

Are you able to perform household chores?
Radio buttons

What is your sober or clean date?
Date

When would you like to move in?
Text field

Why do you want to live in a sober & clean house?
Text field

How did you hear about our program?
Text field

What other information should we consider when reviewing your application?
Text field

Why do you think you are a good fit for a sober and clean living opportunity?
Text field