General
Tell us about yourself
What is your first name?
Client first name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your marital status?
Client marital status
Are you a veteran?
Client veteran status
Tell Us About Yourself
Please tell us a little bit about your history and what brought you to where you are today, why you want to get sober, if you've ever had periods of sobriety in the past, etc.
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Medical History
Tell us about your medical history.
When was your last drink/drug?
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
What mental health diagnoses have you been clinically diagnosed with? 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 plan to 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
Occupancy
When are you looking to move in?
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How long will you be staying with us?
Client estimated length of stay