Application

Reflections Recovery Home

  
Welcome to Our Intake Form
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
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran status
How did you learn about Reflections?
Text field
Are you willinig to make a 3-month commitment to Reflections Sober Living Home Program?
Dropdown

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

Emergency Contacts

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

Insurance

Enter your insurance provider(s).
Insurance

Medical History

Tell us about your medical history.
Are you willing to abide by Reflections Restricted Medication Policy? Click Here for Reflections restricted medication list.
Radio buttons
Are you currently seeing a psychologist, psychiatrist, or mental health professional?
Radio buttons
If yes please explain:
Text field
Have you ever attempted suicide?
Radio buttons
If yes, date of incident.
Text field
Do you consider any of the following behaviors or symptoms to be problematic?
Checkboxes
How long have you been using alcohol and/or drugs?
Text field
When was the date of your last use?
Text field
How do you identify yourself?
Checkboxes
List all drugs you have used in the past 3 years:
Text field
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Sobriety Date (the date of first day 100% without drugs or alcohol):
Text field
Are you willing to abide by the zero-tolerance (absolutely no drug or alcohol usage) policy of Refections?
Checkboxes
Are you willing to submit to random drug tests and preliminary breath tests?
Checkboxes
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
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
 

Medications

List the medications you are currently prescribed.
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

Legal History

 
Are you currently involved with the legal system in any way?
Checkboxes
If yes please explain:
Text field
Are you required to register for any purpose?
Checkboxes
if yes, why:
Text field
Are there any restraining orders against you or by you?
Checkboxes
WHO?
Text field
Relationship:
Text field
Are you currently under parole, probation, or suspended imposition of a sentance?
Checkboxes
Do you have a history of violent crimes on your record?
Checkboxes
Probation Officer Name:
Text field
Probation Officer Phone Number:
Text field
Attorney Name:
Text field
Attorney Phone Number:
Text field
Are you willing to sign a release of information for Reflections to communicate with these individuals?
Checkboxes

Sober Living History

Tell us about any sober livings you've previously been admitted into.
SoberLivingHistory
Are you willing to attend required 12-step meetings? (AA, NA, Celebrate Recovery 90 meetings in 90 days initially)
Checkboxes
Do you currently have a sponsor?
Checkboxes
If yes Sponsors Name:
Text field
Phone Number:
Text field
If no, are you willing to obtain a sponsor within 2 weeks of moving in?
Checkboxes
Are you willing to meet face-to-face with your sponsor once per week?
Checkboxes

Employment

Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"
EmploymentHistory
Financial Information
Are you able to afford Reflections' montly membership fee of $450?
Checkboxes
Do you have the $225 minimum move-in fee?
Checkboxes
How will you pay the move-in fee?
Text field