General
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
Treatment & Medical History
When was your last use date?
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
Have you been clinically diagnosed with anything? 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 attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
Tell us about any treatment centers you've previously been admitted to:
TreatmentCenterHistory
List the medications you are currently prescribed:
Medication
Enter your insurance provider:
Insurances
What is your current mental wellness practice? (meditation, breathwork, reading, etc)
Client medical notes
What is your current physical wellness practice? (yoga, running, weightlifting, etc)
Client medical notes
Legal History
Are you currently on probation?
Probation
Do you have a criminal history?
Criminal History
Client Referral Source
Who referred you to us?
Occupancy & Sober Living History
When are you looking to be admitted?
Date
What is the estimated length of stay?
Client estimated length of stay
Tell us about any sober livings you've previously been admitted into:
SoberLivingHistory
What are you hoping to get from a sober living?
Client notes
Are you looking for a single room or double room?
Client notes