General
First Name: Resident first name
Middle Name: Resident middle name
Last Name: Resident last name
Your Mailing Address:
Street Address:Client Address
City:Client City
State:Client State
Zipcode:Client Zip
Email: Resident email Phone Number: Resident phone
Gender: Resident gender Birthdate: Resident birthdate
School: Resident school
Current Employment: Resident current employment
Marital status: Resident marital status
Was there any criminal/drug/domestic violence involvement in relationship: Text field
Race: Resident race
Veteran: Resident veteran status
Status: Resident status
Referral Information:
Name of Referral:Client referral source
Name of Referral Orginization: Client referral source
Referral E-mail:Client referred by
Referral Phone Number: Client referred by
Contacts
Contact #1
Name: Contact 1 name Phone: Contact 1 phone
Type: Contact 1 type Email: Contact 1 email
Contact #2
Name: Contact 2 name Phone: Contact 2 phone
Type: Contact 2 type Email: Contact 2 email
Contact #3
Name: Contact 3 name Phone: Contact 3 phone
Type: Contact 3 type Email: Contact 3 email
Contact #4
Name: Contact 4 name Phone: Contact 4 phone
Type: Contact 4 type Email: Contact 4 email
Criminal History
Are you a registered sex offender:Text field
Have you ever been convicted of arson:Text field
Do you have a history of violence to yourself or others while not under the influence: Text field
Are you on probation/Parole: Checkboxes
If Yes, please provide Probation officers information:
Name: Contact 10 name Phone: Contact 10 phone
Type: Contact 10 type Email: Contact 10 email
Do you have any legal involvement: Text field
List any Outstanding Legal Issues: Text field
What for:Text field
Pending Court Dates: Date Date Where do you have court: Text field
Previous Treatments
Treatment Center #1
Name: Treatment center 1 name
Started: Treatment center 1 started Ended: Treatment center 1 ended
Treatment Center #2
Name: Treatment center 2 name
Started: Treatment center 2 started Ended: Treatment center 2 ended
Treatment Center #3
Name: Treatment center 3 name
Started: Treatment center 3 started Ended: Treatment center 3 ended
Notes: Treatment center 3 notes
Treatment Center #4
Name: Treatment center 4 name
Started: Treatment center 4 started Ended: Treatment center 4 ended
Notes: Treatment center 4 notes
Medical History
Drug of Choice: Resident substance of choiceOther Use:Client substances of choice
Date of last use: Resident sobriety date
Allergies: Resident allergies
Referred by: Resident referred by
Physical/Medical Conditions:Text field
Psychological Conditions: Text field
Do you have thoughts of suicide: Text field
Any Health Care Directives:Checkboxes Text field
Are you willing to commit to recovery and follow a plan outlined by WisHope: Checkboxes
Medication
Medication #1
Medication: Medication 1 name Dosage: Medication 1 dosage
Medication #2
Medication: Medication 2 name Dosage: Medication 2 dosage
Medication #3
Medication: Medication 3 name Dosage: Medication 3 dosage
Medication #4
Medication: Medication 4 name Dosage: Medication 4 dosage
Medication #5
Medication: Medication 5 name Dosage: Medication 5 dosage
Medication #6
Medication: Medication 6 name Dosage: Medication 6 dosage
INSURANCE
Policy Holder Name:Text field Policy Holder DOB: Text field
Insurance Provider Name:Text field Insurance Provider Phone: Text field
Member ID Number:Text field Group Number:Text field
Type of Policy: Dropdown
HOUSING COST
What Type of Programming are you looking for: Dropdown
Structured Housing costs are $900 for the 1st month. This includes four weeks of housing cost,
Housing admission fee, amd four $50 food cards. Every month after that $800 per month
which includes four $50 food card per week. Weekly housing cost are $150.
Independent Housing cost are $800 for the 1st month. This includes four weeks of housing cost
and housing admission fee. Weekly housing costs are $150.
How will your housing cost be paid for: Text field
Payment Payer: Resident payment payer
Projected Admit Date: Date