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