Name: Client first nameClient last name
Phone number: Client phone
Preferred Pro-nouns: Client pronoun
Clients Gender: Client gender
D.O.B: Client birthdate SSN: SSN
 Admin Date/ Desired Entry Date: Client admit date

Planned Exit Date (9 months recommended): Date
Address:Client AddressClient City
State: Client State
Zip: Client Zip
Emergency Contact/Relative:Text field
Phone Number:Client phone
How long have you been using alcohol and/or drugs? Text field
How do you identify yourself: Dropdown

History of seizures: Dropdown
List ALL the illicit drugs that you have used in the past 3 years: Text field
What was the last drug used and when: Text field
(This information will be used to determine urinalysis in the future, so be 100% honest)
Sobriety Date (the date of first day 100% without drugs or alcohol): Date

Probation Officer: Text field Phone Number:Client phone
Wellness Court? Dropdown
Are you on a Court Order/EDO? Dropdown

Attorney: Text field  Phone Number: Client phone
Employment: Text field Phone Number: Client phone
AA/NA Sponsor: Client sponsor Phone Number: Client phone
Counselor: Text field Phone Number: Client phone
Doctor: Text field Phone Number: Client phone
Marital Status: Client marital status
Prior Treatment facilities or centers: TreatmentCenterHistory
Criminal Record: Criminal History
Do you have ANY mental health issues or diagnosis? Dropdown
If yes, what: Text field

Do you have ANY physical health/medical issues or disabilities?  Dropdown

If yes, what: Text field

Have you been prescribed any medications within 6 months: Dropdown

List ALL medications prescribed in the past 6 months, that you are currently taking, and the last date taken
1. Last taken: Text fieldDate
2. Last taken: Text fieldDate
3. Last taken: Text fieldDate
Are you required to register for any purpose? Dropdown
If yes, why: Text field

Are you a sexual offender? Dropdown

Are there any Restraining Orders against you or by you? Dropdown
Who: Text field
Relationship: Text field

Are you affiliated with anyone in MHA Sober Living? Dropdown
Who: Text field
Relationship: Text field

Are you filling this out for an individual? Dropdown
If yes, what is your name? Text field

Today's date: Date