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 Submitted
Date
Submitted By
Text field
*Expect to Enroll
Text field
Resident Information
*Name
Client first nameClient middle nameClient last name
Gender
Client gender
*Date of birth
Client birthdate
Age
Text field
SSN
SSN
*Address
Client AddressClient CityClient StateClient Zip
*Phone
Client phone
Phone Type
Radio buttons
*Email
Client email
Ethnicity/Race
Client ethnicityClient race
Height/Weight
Text field
School Grade
EducationHistory
Religious Preference if any
Text field
Parent/Guardian/Sponsor Information (PRIMARY)
Briefly describe the relationship between this person and the applicant
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Parent/Guardian/Sponsor Name and Phone
Text fieldText field
Parent/Guardian/Sponsor Email
Text field
Parent/Guardian/Sponsor Contact Method
Radio buttons
Emerg. Contact-if different
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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.)
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Financial and Logistics
I will have Transportation
Radio buttons
I will be financial responsible for my own program fees
Radio buttons
I will have support from family/other for my program fees
Radio buttons
I will be enrolled in a form of higher education
Radio buttons
I am employed
Radio 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 addict
Radio buttons
*Sobriety Date
Text field
I am planning to attend an aftercare or IOP program
Radio buttons
I am planning to attend 90 days of meetings
Radio buttons
Are you discharging from a substance abuse program?
Radio buttons
If yes, list facility name, address, counselor, and phone number
Paragraph
*Do you take prescription drugs?
Radio buttons
*If yes, list prescribe drugs, reason, prescribing doctor frequency of doses
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Please list all allergies and medical restrictions:
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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.
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*Have you ever been convicted of a felony?
Radio buttons
If, yes please explain. (If no put n/a please)
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*Have you ever been accused or convicted of a sexual offense?
Radio buttons
If, yes please explain. (If no put n/a please)
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Previous Treatment
Paragraph
Successful completion?
Radio buttons
Insurance Information
Primary Insurance Company
Text field
Benefits Phone
Text field
Policy Number
Text field
Policyholder's Name
Text 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