Full Name: Client first name Client middle name Client last name
Present Address: Client Address Client City Client State Client Zip Previous Address: Text field
Date of Birth: Client birthdate SSN: SSN Phone: Client phone
How can I reach you today:Text field
ID / Driver's License number and State: Text field
Initials Text field Verified by Initials
Substance Use History: Client substances of choice
Are you currently taking any MAT medications?
Are you currently in Recovery?
Last Date of Use:Date
Are you currently in a residental / inpatient or outpatient facility?
If yes: Text field
Are you currently or have you previously stayed in a sober home, half way home, or similar?
If yes list names of places and dates stayed: Text field
Do you plan on attending outpatient treatment upon moving in?
If yes list name and number: Text field
Have you ever been convicted of a crime?
If yes, explain: Text field.
Do you currently have legal obligations, parole, probation, CPS, stay of commit, case worker, etc"
If yes, explain: Text field
Above contact names and numbers: Text field Do you have any pending charges or court dates?
Please list only 1 Family Member
Please list only 1 Emergency Contact
Current Employment: EmploymentHistory
House preference Text field
I have reviewed the Resident Agreement online Signature