Game Changers Foundation Admissions Application

General Information

Name: Client first nameClient last name

Date of Birth: Client birthdate

SSN: SSN

Phone Number: Client phone

Physical Address: Client Address

Mailing Address (if different from physical): Text field

Email Address: Client email

Gender: Client gender

Race: Client race

Religion: Text field

Veteran Status: Client veteran status

Marital Status: Client marital status

Do you have children: Radio buttons

Children: Family Members

Drug Use

What is your Drug of Choice: Client substances of choice

How long have you been in addiction: Text field

Describe the last 6 months of drug or alcohol use:

 Paragraph

Have you ever sought treatment before: Radio buttons

If yes, what is your treatment history:

SoberLivingHistory

TreatmentCenterHistory

Criminal History

Do you have any pending charges: Radio buttons

If yes, describe what happened and what county it happened in:

Paragraph

Are there release stipulations related to your pending charges: Radio buttons

If yes, please describe:

Paragraph

 

Do you have any active warrants? 

Radio buttons

If so, please describe:

Paragraph

Are you currently facing or have you ever been convicted of any sex related crimes: Radio buttons

If yes, please describe:

Paragraph

Are you currently facing or have you ever been convicted of any violent crimes: Radio buttons

If yes, please describe:

Paragraph

Are you currently on probation or parole: Radio buttons

If yes, please provide the officier's name, phone number, email, and business address:

Name: Text field

Phone Number: Text field

Email: Text field

Address: Text field

County: Text field

Do you have any mandatory court, probation/parole, or other legal appointment while in
the program: Radio buttons

Date: Date

Officer's Name: Text field

Location: Text field

Do you have a Lawyer?

Name: Text field

Phone Number: Text field

Email: Text field

Address: Text field

Medical History

Have you been diagnosed with any mental health disorders: Radio buttons

Is yes, please list below:

Client health problems

Do you have any allergies:

Client allergies

Please list your medications if any:

Medication

Will you have any medical appointments while in the program: Radio buttons

If yes, please list the date(s), location(s), and appointment type(s) below:

Paragraph

Employment Information

Please list your last 2 jobs (busienss name, address, phone number, manager's name):

EmploymentHistory

Referral Information

How did you hear about us:

Checkboxes

If you heard about us through Alumni or Staff please provide their name: Text field

Contact Information 

Contact #1  (Person responsible for payment)

Contact

Contact #2 (Emergency Contact)

Contact