General
Tell us about yourself
What is your Legal full name?
Text field
What is your Preferred first name? (if same as legal name please enter that)
Client first name
What is your Preferred last name? (if same as legal name please enter that)
Client last name
What name do you prefer to go by?
Client nickname
What are your pronouns?
Client pronoun
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran
Medical History
Tell us about your medical history.
When was your last use date?
Recovery history 1 relapse date
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Have you been clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
What allergies do you have? No allergies? Move on to the next question.
Client allergies
Have you had any of the following tests?
Medical Tests