Client first nameClient middle nameClient last name

Client birthdateClient genderClient raceClient ethnicity

Client AddressClient CityClient StateClient Zip

Client phoneClient email

TreatmentCenterHistory

LivingArrangementHistory

RecoveryHistoryClient sponsor

Kinds of meetings attended.

Client kinds of meetings attended

Substance of choice.

Client substances of choice

If substances are not an issue, are there any mental health diagnosis?  Please Explain.

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Medication

Are you currently employed?

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EmploymentHistory

Skills you possess:  Tradecraft, Office, Medical, Creative, Technical, etc.

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EducationHistory

Desired Career or Field of Study

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Please list all felony convictions and incarceration periods.

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Please list any other charges on your record (misdemeanor).

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Family Members

Are you currently estranged from your family?  Please explain.

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How have the mistakes of your past kept you from achieving things you wish you could have done?  Please be specific.

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As best you can, describe the difficult, life-defining circumstances, that led you to where you are today.  Just how dark did the darkness become?  Be completely open, ONEsource is about healing, restoration, and abundant life with God, NEVER judgement, only encouragement.

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What does the word "surrender" mean to you today?

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What would you do with just one wish?

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If you could be anything you wanted to be, any profession or field of study, what would that be?  Why?

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Spiritual Growth & Enlightenment:  Do you believe in a power greater than yourself?  What have you "come to believe about a power greater than our own who restores us to sanity" as described in step 2 of the 12 steps?

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What do you hope to gain by joining our community at ONEsource?

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ONEsource is a spiritual journey to find oneness with God in everyday living.  We are not religious and do not intend to force religion on anyone.  This is a free space to explore, ask questions, learn, and grow in spiritual understanding of God, as we understand Him.  Through this process we hope to grow and maintain community with one another and God, seeking confident connection and trust with one another is vital to overcoming the secrets we have kept hidden and taking new steps to find who we are in God and who we were created to be.

By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.

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