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 gender identity?
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What are your pronouns (if applicable)?
Text field
What is your sexual orientation?
Text field
What is your transition status (if applicable)?
Text field
Comfort Level in LBGTQIA+ Spaces (if applicable)?
Text field
Are there any specific concerns or needs you'd like us to be aware of to maintain a safe environment for you?
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What is your race/ethnicity?
Client race
What is your marital status?
Client marital status
Medical History
Tell us about your medical history.
When was your last relapse date?
RecoveryHistory
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?
Radio buttons
If yes, please explain:
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Do you have any medical health problems?
Radio buttons
If yes, please explain:
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Do you have any medical allergies?
Client allergies
Entry and Transportation
What is the earliest date you wish to enter?
Text field
Do you have your own vehicle?
Radio buttons
Sober Living History
Tell us about any sober livings you've previously been admitted into.
Have you ever lived in a sober living?
Radio buttons
If yes, enter the name:
Text field