Client Application



Client level/phase

Client facility

Client last name               Client first name                  Client middle name


AGE:Text field DATE OF BIRTH: Client birthdate

PLACE OF BIRTH: Text field Client race

Marital Status:   Client marital status                  Social Security Number: SSN

Permanent Address: Client Address

City:Client City ST: Client State Zip Code: Client Client Zip

Phone/Home: Client phone Phone/Work: Text field

Do you have a current Drivers License?   CheckboxesCheckboxes

Do you have current auto insurance coverage?  CheckboxesCheckboxes

Clients are required to have current driver’s license, current registration and auto insurance if they will be operating a motor vehicle while a client at RISE UP RECOVERY residences.

Spouse/Next of Kin: Family Members

Permanent Address: Text field

City: Text field ST: Text field Zip Code: Text field

Phone/Home:Text field/Work: Text field

Emergency Contact: Contact

(Clients must sign a release for this person.)

Permanent Address: Text field

City: Text field ST: Text field Zip Code: Text field

Phone/Home: Text field Phone/Work: Text field


Were you mandated to treatment?   CheckboxesCheckboxes

Do you have legal charges pending?   CheckboxesCheckboxes

Are you taking any medications?   CheckboxesCheckboxes

List Medications: Medication

How did you hear about RISE UP RECOVERY residences?  Client Referred By


Substance Abuse History




Have You Been Arrested? CheckboxesCheckboxes


List Charges and Any Time Served:

Text field


Date of Last Use and What was Used: Date Text field

 Drug of Choice:

Client substances of choice


List Orders Other Than Addiction:

Client medical notes