Resident Application

 

Full Name: Client first name Client middle name Client last name*Required 

Present Address: Client Address Client City Client State Client Zip 

Previous Address: Text field

Email: Client email*Required 

Date of Birth: Client birthdate *Required 

SSN: SSN  *Required

Phone: Client phone

How can I reach you today : Text field*Required 

ID / Driver's License number and State: Text field 

Initials Text field Verified by Initials *Required

 

Substance Use History: Client substances of choice *Required

Are you currently taking any MAT medications? 

Radio buttons 

Are you currently in Recovery?

Radio buttons 

Last Date of Use:Date*Required 

Are you currently in a residental / inpatient or outpatient facility? 

Radio buttons

If yes: Text field

Are you currently or have you previously stayed in a sober home, half way home, or similar? 

Radio buttons

If yes list names of places and dates stayed: Text field

Do you plan on attending outpatient treatment upon moving in? 

Radio buttons

If yes list name and number: Text field

 

Legal History

Have you ever been convicted of a crime? 

Radio buttons

If yes, explain: Text field. 

Do you currently have legal obligations, parole, probation, CPS, stay of commit, case worker, etc" 

Radio buttons

If yes, explain: Text field 

Above contact names and numbers: Text field Do you have any pending charges or court dates? 

Radio buttons

If yes, explain: Text field 

 

Contacts

Please list only 1 Family Member

 Family Members

Please list only 1 Emergency Contact

 Contact

 

Employment 

Current Employment: EmploymentHistory

 

 

Medication Information

Medication

 

House preference Text field

 

Print name: Text field

Date of Birth: Client birthdate

I have reviewed the Resident Agreement online  Signature*Required