Client first nameClient middle nameClient last name

Client phone       Client email

 

Client Address     Client City    Client State   Client Zip

 

Client gender     Client ethnicity     Client race

 

 DOB Client birthdate     Marital Status Client marital status

 

Any Children?  Checkboxes        If yes, how many?Text field

 

Are you currenlty assisting with any child support?

Checkboxes

Are you a veteran? Client veteran status

 Social Security SSN

If you have lived in any other states, please list.

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Client Referred By

If not listed above, who refered you?

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      ***Are you willling to commit to a 12 month program? Checkboxes

      ***Why is now the time, and why Jeremiah House?

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Medical

Have you been diagnosed with any mental illness Checkboxes

Client diagnosis

If Yes, Please Explain.

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Client health problems

Please explain.

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HAVE YOU EXPERIENCED OR DO YOU PRESENTLY HAVE A PHYSICAL AILMENT, INJURY, HANDICAP OR MEDICAL PROBLEM THAT WOULD PREVENT YOU FROM PERFORMING MANUAL LABOR WHILE ENROLLED AT AT JEREMIAH HOUSE?

Checkboxes 

Please explain.

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List current medications

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 Client medical notes

Client allergies

 

Have you ever attempted suicide? Checkboxes

If yes, please explain.

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Are you currently having suicidal thoughts? Checkboxes

If yes, please explain.

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Education 

Please at minimum, give hightest degree completed.

Client school

EducationHistory

 

Drug Usage

 

Client substances of choice

Age you started using each, and lenght of use

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Have you every had any overdoses?  Dropdown

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Criminal History

 

Are you on Probation Checkboxes

If yes, with who?Text field

 

Any viloent crimes? Checkboxes

Please expain.

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 Other charges.

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Any charges from other states?Checkboxes

Please explain.

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Are you a sex offender? Checkboxes

 

 

TreatmentCenterHistory

 

RecoveryHistory

 

 Empoyment

Are you currently employed? Checkboxes

If so, by who? 

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Insurance

Are you currently recieving Snap/ Food Stamps? Checkboxes

Are you currently on Sooner Care, or any other insurance?  

Policies numbers are not needed, only the Name of insurance provider.

Insurances  

 

Are you receiving welfare, unemployment compensation, disability payments, workman’s comp, alimony, VA benefits, or other income?

 Checkboxes

Please explain.

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