Canterbury House Application

Canterbury House Initial Application

Welcome to the Canterbury House 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 gender?
Client gender
What is your marital status?
Client marital status
Do you have any children?
Family Members
Are you a veteran?
Client veteran status
How did you hear about Canterbury House?

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
Client Address
Client City
Client State
Client Zip
Emergency Contact:

Contact 

 

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 are your goals for the next 3 months?

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 What are your goals for the next 6 months?

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What are your expectations of staying at Canterbury House?

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Are you on Probation or Parole, or have any pending charges?

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Treatment Center History

 
What facility will you be staying at?
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
When will the you be discharged?
Client discharge date

Sober Living History

Tell us about any sober livings you've previously been admitted into.
SoberLivingHistory

 What got you here today? 

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