🔹  Intake Form - Sober Home Inquiry

🧍 Applicant Information

• Full Name Client first name Client last name

• Date of Birth Date

• Phone Number Client phone

• Email Address Client email

• Preferred Contact Method Dropdown

📍 Referral Source

• How did you hear about us? Dropdown

• Referral Name or Organization Text field

• Referral Contact Info Text field

🧠 Recovery Status

• Are you currently in treatment? Checkboxes

• Expected discharge date Date

• Have you lived in a sober home before? Checkboxes
  if yes, where? 
  Paragraph

📅 Desired Move-In Date

• Preferred Move-In Date Date

🚨 Medical & Legal

• Do you have any medical conditions or medications we should be aware of? Text field

• Are you currently on probation or parole? Checkboxes

• Case Manager/PO Name & Contact Paragraph

• Are you a Veteran?  Dropdown

💬 Additional Notes

• Anything else you'd like us to know? Paragraph

✅ Consent

• Checkboxes 

• Signature Field Signature

• Date Date