Application

Application for Admission 

Mid-Coast Recovery

Date: Date

 

Name: Client first nameClient last name DOB: Client birthdate

Address: Client AddressClient CityClient StateClient Zip

Phone: Client phone Email: Client email

Emergency Contact: 

Contact

Current Treatment Center: 

Treatment Center #1
Type:

Treatment center 1 type

Treatment Center Name:

Treatment center 1 name

Street Address:

Treatment center 1 address

City:

Treatment center 1 city

State:

Treatment center 1 state

Zip:

Treatment center 1 zip

Admitted On:

Treatment center 1 started

Discharged On:

Treatment center 1 ended

Reason for Discharge:

Treatment center 1 reason for discharge

Notes:

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Have you ever lived in a sober home?

If yes.. 

SoberLivingHistory

Substance Use Drug How Long Abused How Long Since Last Use
  Text field Text field Text field
  Text field Text field Text field
  Text field Text field Text field

Which recovery program are you currently working or interested in: Text field

What meetings do you attend: Text field Do you have a sponsor: Text field

What is your current source of income: Text field Monthly income: Text field

Pending legal matters: 

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Any felony convictions: 

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Are you requiredf to register as a sex offender: Text field

Have you been convicted of arson: Text field

Do you have any other mental health diagnosis: Text field

What is that diagnosis and treatment: 

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Have you ever experienced any suicidal ideations, attempts, or received in-patient treatment for self-harming behaviors, when: 

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Current Medications: 

Medication

Why do you think you're a good fit for sober living: 

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Signature: Signature Date: Date