A DOGHOUSE APPLICATION

 

 Doghouse Sober Living Application

Welcome to the Sober Home intake wizard
Click next to begin!

General

Tell us about yourself
What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
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 status

Contact Information

How can we reach you?
What is your email address?
Client email
At what phone number can we best reach you at?
Client phone
Street Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip

Contacts

Give us a few people that we can reach out to in case of an emergency.
Contact

Insurance

Enter your insurance provider(s).
Insurance

Medical History

Tell us about your medical history.
When was your last relapse 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
Have you ever attempted suicide? If yes, Please include the date, location and if you were hospitalized. If no, Say no attempts. 
Client medical notes
What allergies do you have? No allergies? Move on to the next question.
Client allergies
Are you pregnant? Not pregnant? Move on to the next question.
Dropdown

Have you had any of the following tests?

Medical Tests
 

Medications

List the medications you are currently prescribed.
Medication

Criminal History

Tell us about your criminal history

_______________________________________________________________________________________

Criminal History

If any, list all criminal convictions*: Paragraph

Are you required to register as a Narcotic Offender?

Dropdown

Are you required to register as a Sex Offender?

Dropdown

Are you required to register as an Arson Offender?

Dropdown

If you are required to register, are you currently registered as required by law?

Dropdown

If any, list current criminal street and/or prison gang participation:

 Text field

Are you currently on Probation or Parole?

Dropdown

 If yes, Probation/Parole Officer’s Name and Phone Number:

Contact

  

Treatment Centers

Tell us about any treatment centers you've previously been admitted into.
TreatmentCenterHistory

 Referral Source

 
Who referred you to us?
Client Referred By

Occupancy

 
What facility will you be staying at?
Client facility
What date are you planning to move in?
Date
What is the estimated length of stay?
Client estimated length of stay
When will the you be discharged?
Client discharge date

Sober Living History

Tell us about any sober livings you've previously been admitted into.
SoberLivingHistory

Employment

Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"
EmploymentHistory

Living Arrangement

Tell us about your living arrangement prior to moving into this facility
LivingArrangementHistory
 
 Click submit form. Thank You!