Application Form

 

Bright Spot Sober Living Intake

Click next to begin!

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

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

Insurance

Enter your insurance provider(s).
Insurance

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
 
 

Medications

List the medications you are currently prescribed.
Medication

Treatment Centers

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

Client Referral Source

 
Who referred you to us?
Text field

Occupancy

 
When are you looking to move in?
Text field
How long will you be staying with us?
Client estimated length of stay

Sober Living History

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