Waitlist Pre-Screen

 

Waitlist Pre-Screen

Fill out the following information to the best of your ability, and someone will contact you as soon as possible.

General

Tell us about yourself.
What is your first name?
Client first 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? (At this time, Stable Recovery is a men's-only program. We're planning to launch a women's program in early 2026.)
Client gender
Are you a veteran?
Client veteran status
 

 

Substance Abuse and Medical History

What is your sobriety date, or the date of your last relapse if you are not currently sober?
RecoveryHistory
What is/are your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Are you currently on any medication assisted treatment (MAT)?
Radio buttons
If yes, which medication?
Text field
How many times have you participated in an addiction treatment program?
Text field
Are you allergic to any animals?
Radio buttons
If yes, which animals?
Text field
Have you been clinically diagnosed with any of the following mental health conditions? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any physical limitations?
Radio buttons
If yes, please briefly describe.
Text field
Can you lift 50 pounds?
Radio buttons
 

Current Situation

 

What is your current living arrangement?

LivingArrangementHistory

If you are currently in a treatment program, what is your out date?
Date
Are you currently in an Intensive Outpatient Program (IOP) or Partial Hospitalization Program (PHP)?
Radio buttons
If yes, what is your projected completion date?
Date
Are you court ordered to go to a transitional/sober living?
Radio buttons
Are you currently on probation or parole?
Radio buttons
If yes, what jurisdiction controls your sentence?
Text field
 
 

Employment

Do you have any experience working with horses?

Radio buttons

If yes, provide a brief explanation:

Text field

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

EmploymentHistory
 
 

Referral Source

How did you hear about Stable Recovery?
Client Referred By
 

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