Application

RYAN Healing Center Intake Application

Welcome to the intake wizard
Click next to begin!

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 race
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 at?
Client phone
Street Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip

Contacts

Give us a contact with name and number that we can reach out to in case of an emergency.
Contact

Medical History

Tell us about your medical history.
When was your last date of use?
Recovery history 1 relapse date
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? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
 

Medications

List the medications you are currently prescribed.
Medication

Client Referral Source

 Who referred you to us?

Text field

Occupancy

Are you willing to stay one year?
Text field
What date will you be admitted on?
Client admit date

History

Have you been a victim of Human Trafficking?
Text field
 
Describe current/past legal issues
Paragraph