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 ethnicity

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?  Client phone

Street Address:  Client Address

City:  Client City

State:  Client State

Zip code:  Client Zip

 

Contacts

Give us a few people that we contact in case of an emergency.

Contact

 

Medical History

Tell us about your medical history.

RecoveryHistory

What is your primary substance(s) of choice? 

Client substances of choice

Have you been clinically diagnosed with anything? 

Client diagnosis

Do you have any health problems? 

Client health problems

What kind of meetings do you attend?  

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          

 

Medications

Medication

 

Treatment Centers

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

TreatmentCenterHistory 

 

Criminal Justice

Tell us about any past or present involvement with CJ. If you are on Parole, please enter the information(probation officer/district and phone number) in the note field.

Probation 

Client notes

 

Client Referral Source

Who referred you to us? 

 Client Referred By

Occupancy

To which facility are you applying?

Client facility

When are you looking to move in? 

Client admit date

 

Sober Living History

Tell us about any sober living home 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 before moving into this facility

LivingArrangementHistory