Application

Welcome to Kennedy's Place! 

Application Form

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
Do you have funding? If so, what is the source, and the conditions?
Text field    
 

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

Emergency Contact

Please provide contact information for at least one emergency contact. 
Contact

Transportation

What is your primary mode of transportation?
Text field
Do you have a valid driver's license?
Text field
If you have a personal vehicle, do you have auto insurance?
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
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
Do you have health insurance?
Insurances
 

Medications

List all of the medications you are currently prescribed, including dosage and frequency. Any medications, especially controlled substances, must be kept in a resident-provided lock box with a pill count. 
Medication

Treatment Centers

Tell us about any treatment centers you've previously been admitted to. If you are in the DOC program, please enter your DOC number and all other details here.
TreatmentCenterHistory
 
 

Sober Living History


Tell us about any sober living homes you've previously been admitted to. 

SoberLivingHistory

Occupancy

What facility would you like to stay at? Everett, Arlington, Mukilteo, Wenatchee, Yakima
Client facility
What date will you be admitted on?
Client admit date
What is the estimated length of stay?
Client estimated length of stay

Employment

Tell us about your employment status.
If you're currently unemployed, please enter "unemployed." If you plan to enroll in school, you may enter that information here as well. 
EmploymentHistory

Living Arrangement

Tell us about your living arrangement prior to moving into this facility
LivingArrangementHistory