Simply Grace Application
Welcome to Simply Grace!
Thank you for considering Simply Grace for your recovery housing.
Please complete this to the best of your ability. If you don't know the answers please enter n/a.
Fields with the asterisk (*) are required.
*Date SubmittedDate Submitted ByText field
Expect to EnrollText field
Resident Information
*NameClient first nameClient middle nameClient last name
Gender Client gender
Date of birthClient birthdate AgeText field
SSNSSN
*AddressClient AddressClient CityClient StateClient Zip
*PhoneClient phone
Radio buttons
*EmailClient email
Ethnicity/Race Client ethnicityClient race
Height/WeightText field
School Grade
CheckboxesText field
Religious Preference if anyText field
Parent/Guardian/Sponsor Information (PRIMARY)
Briefly describe the relationship between this person and the applicant
Paragraph
Parent/Guardian/Sponsor Name and PhoneText fieldText field
Parent/Guardian/Sponsor EmailText field
Parent/Guardian/Sponsor Contact MethodRadio buttons
Emerg. Contact-if differentParagraph
Referral Information
*How did you first hear about Simply Grace?Please give the name(s) of the referral source including phone, fax number and email
Paragraph
Referral Name/Phone/Email Text fieldText fieldText field
Can we Contact?Radio buttons
*Reason for referral: Chief complaint and symptoms (please be very specific including issues at home and school
as well as any symptoms noticed such as mood changes, etc.)
Paragraph
Financial and Logistics
I will have TransportationRadio buttons
I will be financial responsible for my own program feesRadio buttons
I will have support from family/other for my program feesRadio buttons
I will be enrolled in a form of higher educationRadio buttons
I am employedRadio buttons
If not employed are you interested in gaining employment during your stay?Radio buttons
If no, what are your plans?Text field
Recovery Information
*I am recovering alcoholic/ drug addictRadio buttons *Sobriety DateText field
I am planning to attend an aftercare or IOP programRadio buttons
I am planning to attend 90 days of meetingsRadio buttons
Are you discharging from a substance abuse program?Radio buttons
If yes, list facility name, address, counselor, and phone number
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Medical History
*Do you take prescription drugs?Radio buttons
*If yes, list prescribe drugs, reason, prescribing doctor frequency of doses
Paragraph
Please list all allergies and medical restrictions:
Paragraph
Food allergies
Radio buttons If yes, please explain:Paragraph
Weight loss or gain of 10 pounds or more in the last 3 months
Radio buttons If yes, please explain: Paragraph
Decrease in food intake and/or appetite
Radio buttonsIf yes, please explain: Paragraph
Dental problems Radio buttons
If yes, please explain: Paragraph
Eating habits or behaviors that may be indicators of an eating disorder, such as binging or inducing vomiting
Radio buttons If yes, please explain:Paragraph
Are you currently experiencing any pain?Radio buttons If yes, please answer the below questions.
1. Pain Intensity On a scale of 0 to 10, where 0 = No pain 10 = Worst possible pain
Please rate the severity of your pain:Text field
Current pain intensity: Text field Worst pain in the last 24 hours: Text field Least pain in the last 24 hours:Text field
2. Pain Location Text field
3. Pain Description Text field
Please describe your pain using the following terms (check all that apply):
Checkboxes
Other: Text field
4. Pain Duration-When did your pain start? Text field
How long does the pain last?
Checkboxes
Other:Text field
5. Pain Triggers
What seems to trigger or worsen your pain? (Check all that apply)
Checkboxes
Other:Text field
6. Pain Relief
What helps to relieve or decrease your pain? (Check all that apply)
Checkboxes
Medications (please list):Text field
Other:Text field
7. Impact on Daily Activities
Please rate how much your pain affects the following activities:
Work or School Checkboxes
Household Chores Checkboxes
Socializing with Friends/Family Checkboxes
Sleeping Checkboxes
Exercising/Physical Activity Checkboxes
Eating Checkboxes
8. Additional Comments
Please provide any other details about your pain or how it impacts your life:Paragraph
Legal History
Do you have any pending court cases other than moving violations?Radio buttons
If yes, explain: (bond, probation, pending court case) if no put n/a please.
Paragraph
*Have you ever been convicted of a felony? Radio buttons
If, yes please explain. (If no put n/a please)
Paragraph
*Have you ever been accused or convicted of a sexual offense?Radio buttons
If, yes please explain. (If no put n/a please)
Paragraph
Previous Treatment
Paragraph
Successful completion?Radio buttons
Insurance Information
Primary Insurance Company Text field Benefits PhoneText field
Policy NumberText field Policyholder's NameText field
Please call Call 214-774-9808 with any questions and to let us know you are ready to move foward.
We're excited to meet you!
Simply Grace Staff