Personal Information
Tell us about yourself
What is your first name?
Client first name
What is your last name?
Client last name
Do you go by another name?
Client nicknameAre you fleeing from a domestic violence situation?
Radio buttons
Contact Information
How can we reach you?
At what phone number can we best reach you at?
Client phone
Currently Residing:
Dropdown
How did you hear about UTurn Recovery Housing?
Client Referred By
Why do you want to live in Sober Living?
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What are your expectations of Sober Living?
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What do you expect to gain from Sober Living?
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Have you lived in Sober Living before?
Radio buttons
If yes, list previous Sober Livings:
SoberLivingHistory
Drug History
Tell us about your drug history.
How long have you been clean/sober?
Text field
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
What age did you being using?
Text field
Do you have a family history of substance abuse?
Radio buttons
Do you struggle with other addictions?
Checkboxes
Are you in treatment?
Radio buttons
If yes, when are you getting out?
Date
What is your previous treatment history?
TreatmentCenterHistory
Recovery
Tell us about your recovery
How serious are you about staying clean/sober? Explain:
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Do you have a relapse prevention plan?
Radio buttons
If yes, what is the plan?
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What are your plans for IOP, aftercare and 12-step meeting participation?
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Do you currently have a sponsor?
Radio buttons
If yes, how is your relationship with your sponsor?
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If no, have you ever had a sponsor?
Radio buttons
What are your plans for getting a sponsor?
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Are you currently attending meetings?
Radio buttons
If yes, what types of meetings are you attending?
Client kinds of meetings attended
What prescription and non-prescribed medications are you currently taking and plan to continue taking?
Medication
Financial Information
Tell us about your financial situation
Are you currently employed?
Radio buttons
What is the highest level of education you completed?
Dropdown
Are you currently enrolled in school?
Radio buttons
If yes, what school?
Client school
How will you be meeting your financial obligations for rent and living expenses?
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Family Information
Tell us about your family
Are you in the process of family reunification?
Radio buttons
Do you have children?
Radio buttons
If yes, what is the situation with them?
Paragraph
Thank you for your interest!
We value proactivity!
Please follow up with Justin Jensen (801) 645-1242 any time after 10:00 am daily!
Just submitting an application doesn't automatically put you on the list! Contact needs to be made to ensure placement!!!