Intake Form
 RJM House/RJM Upon Awakening Application

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?

*If you do not have a phone number or email address, please leave these fields blank.  If you wish to provide other contact information where you can currently be reached, you may add those contacts below in the next section.  Thank 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

Recovery is a team effort.  Please provide the contact information for your support network and other stakeholders in your recovery.  Be sure list and list the following:

1) Emergency Contact (at least one);

2) Referent listed above; 

3) Any care providers and stakeholders in your recovery, including Probation/Parole.

(Provide as much contact information as may be available to you)

Contact

Insurance

Enter your insurance provider(s).
Insurance

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? 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
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
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

List the medications you are currently prescribed.
Medication

Treatment Centers

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

Client Referral Source

 
Who referred you to us?
Client Referred By

Sober Living History

Tell us about any sober livings 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 prior to moving into this facility
LivingArrangementHistory

RJM HOUSE LLC will consider all requests for reasonable accommodations. To submit a request for reasonable accommodation due to a disability, please submit a request in writing to the operator separately from this application. You may request a reasonable accommodation request form from the operator at rjmrecovery@gmail.com.

 

PLEASE CALL OUR INTAKE LINE UPON COMPLETING THIS APPLICATION AT 603-836-4031 TO SCHEDULE YOUR PHONE SCREENING. APPLICATIONS WILL NOT BE CONSIDERED UNTIL YOU CALL OUR INTAKE LINE TO SCHEDULE PHONE SCREENING. WE LOOK FORWARD TO SPEAKING WITH YOU. 

Applicant signature

Signature