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
Admitted On:
Treatment center 1 started
Discharged Date:
Treatment center 1 ended
Reason for Discharge:
Treatment center 1 reason for discharge
Notes:
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Have you ever lived in sober living?
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
Do you currently attend any recovery meetings?: Text field
Do you have a sponsor/mentor: Text field
Do you have a source of income?: Text field Monthly income: Text field
Do you have any pending legal matters? If yes, please describe:
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Do you have any previous convictions? If yes, please describe:
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Are you required to register as a sex offender?: Text field
Do you have any arson convictions?: Text field
Do you have any other mental health diagnosis? If yes, please describe:
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Have you ever experienced any suicidal ideations, attempts, or received in-patient treatment for self-harming behaviors? If yes, please describe:
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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