TTR - Application

Threshold To Recovery Application

Welcome to the Threshold To Recovery Application
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 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
 
INSURANCE WILL BE USED TO ADMINISTER UA'S/BA'S AND CONNECT YOU TO WRAPAROUND SERVICES
 
Who is your current Medical Insurance Provider?
Insurances
What is your current Client ID Number on your current insurance policy?
Text field
 

Medications

List the medications you are currently prescribed.
Medication

Treatment Centers

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

Criminal Background

 

Do you have any felony charges in your past? If so, please explain. If not please write "No".

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Client Referral Source

 
Who referred you to us?
Client Referred By

Occupancy 

What facility would you like to apply for? 
Client facility
What date will the you be admitted on?
Client admit date
What is the estimated length of stay?
Client estimated length of stay

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"

Are you currently employed? If so, with who?

EmploymentHistory

Living Arrangement

Tell us about your living arrangement prior to moving into this facility
LivingArrangementHistory