Application - Tell us about you and what we can help with!

 

Deep Roots Initial Contact Form

Welcome to Deep Roots!
Click next to begin!

General

Tell us about yourself
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 gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran status

Contact Information

How can we reach you?
What is your email address?
Client email
At what phone number can we best reach you at?
Client phone
Street Address:(if homeless put that as address)
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip

Emergency Contacts

Give us a few people that we can reach out to in case of an emergency.
Contact

Are you currently enrolled in Free Through Recovery, Community Connect, or 1915i?

Checkboxes 

If you are enrolled in one of the above programs, what provider are you working with?

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Are you on ND Probation currently?

Checkboxes

If yes, who is your probation officer?

Text field

Insurance

Enter your insurance provider(s). (If you do not have insurance don't worry!)
Insurance

Medical History

Tell us about your medical history.
When was the last time you used drugs or alcohol?
Text field
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
What allergies do you have? No allergies? Move on to the next question.
Client allergies
 

Treatment Centers

Tell us about any treatment centers you've previously been admitted into.
TreatmentCenterHistory

Client Referral Source

Who referred you to Deep Roots?
Text field

Sober Living History

Tell us about any sober livings you've previously been admitted into. (If you haven't lived in sober living leave blank)
SoberLivingHistory

Employment

Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"
EmploymentHistory

Living Arrangement

Tell us about your living arrangement prior to moving into this facility
LivingArrangementHistory

Please provide any additional information you wish to share.

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Please sign this document giving permission for someone at Deep Roots to contact you.

Signature

If you assisted someone with completing this form, please provide your information if you wish to be contacted as well.

(Name And Phone Number)

Text field