Application

 

 

Recovery Trail

Welcome to the Recovery Trail 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 few people that we can reach out to in case of an emergency.
Contact

 
 

Medical History

Tell us about your medical history.
When was your last relapse date?
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
 
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 1 Text field For? Text field
Medication 2 Text field For? Text field
Medication 3 Text field For? Text field
Medication 4 Text field For? Text field

Treatment Centers

Tell us about any treatment centers you've previously been admitted into.
 Have you ever been to Inpatient Treatment? Checkboxes
When? Text field Where? Text field
 
Have you ever lived in a Sober Living Community? Checkboxes
When? Text field Where? Text field

Occupancy

 
 What is your current living situation? Dropdown
 Other? Text field
What date would you like to be admitted on?
Client admit date
 
Have you read Recovery Trails Guidlines? Checkboxes
Are you willing to agree to the Guidlines? Checkboxes
 
Who Refered you to us?
Dropdown
 
 
 
 

 

 Employment

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

Do you currently have a job? If so Where? Text field

Do you have State ID?

 Checkboxes

Do you have Social Security Card?

Checkboxes

Do you have a Birth Certificate?

Checkboxes

What State were you born in? Text field

Judicial Information

Are or will you be on probation/parole? Dropdown

Officers Name 

Text field

Phone Number

Text field

Are you a registerd Sex Offender?  Checkboxes