*Tribe Recovery Homes Intake Questions

Tribe Recovery Homes Intake Questions

Participant information:

First Name: Client first name 

Middle Name: Client middle name 

Last Name: Client last name

Intake Date: Date

Gender: Client gender 

Race: Client race

Ethnicity: Client ethnicity

Birthdate: Client birthdate

Previous/Family Members/Partners Street Address:Text field

Address: Client Address

City: Client City State: Client State Zip: Client Zip

Sobriety Date: Client sobriety date

Social Security#: Text field

E-mail: Client email

 

Highest level of education completed:

Education 1 degree

Cell phone:  Client phone


Please indicate which method of contact is preferred and if it is ok to leave a message:

Text field

Is it ok to leave a message?

Checkboxes


Emergency Contact Info Including Contact Number:

Name: Contact 1 name

Phone: Contact 1 phone

Relation: Contact 1 type

Is it ok to leave a message?

Checkboxes

 

Have you received help for drug or alcohol dependency? If yes, please specify when, for what and where:

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What is your primary drug of choice?

Text field

 

 


If you are currently under care of a Physician, please specify:

Physician: Condition: Treatments/Medications:
Text field Text field Paragraph
Text field Text field Paragraph
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What is your current employment situation? Check all that apply:

Checkboxes

If "other", please specify

Text field

If currently employed:
What is your occupation? Text field

Employer: Employer 1 name 

 

What is your current financial situation? Check all that apply:

Checkboxes
If "other", please specify:

Text field

What is your legal situation? Check all that apply:

Checkboxes

Please Explain Each Answer Checked
Paragraph

If you are on Parole or Probation, please provide the following:
Location Of Parole/Probation:

Paragraph
Parole/Probation Officer Name:

Text field
Parole/Probation Officer Phone Number:

Text field
Parole/Probation Officer Email Address:

Text field

Please Provide Provide Insurance Information:

Insurance Type: (Medicaid, Medicare, Private Insurance):

Text field
If Private Insurance Please Provide Details:

Provider: Client insurance provider Insurance Plan: Client insurance plan

Group ID: Client insurance group ID Policy#: Client insurance policy #

 

Relationship status:

Client marital status

If "other", please specify:

Text field

 

 

Have You Ever Been On Any Form Of Medicated Assisted Treatments If So Check The Following Treatments You've
Used
Checkboxes


How Many Sober Livings Have You Lived In

Checkboxes


Why Did You Leave Your Last Sober Living

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After A Full Detoxification Period How Many Times Have You Relapsed

Radio buttons

 


Participant Signature: 

First Name: Client first name

Last Name: Client last name

Signature

Date: Date

 

Staff Signature:

Staff First Name: Text field

Staff Last Name: Text field

 Signature

Date: Date