Lead Form

SCREENING APPLICATION:

General

First Name: Client first name 

Middle Name: Client middle name 

Last Name: Client last name

Address: Client Address

City: Client City State: Client State Zip: Client Zip

Email: Client email Phone Number: Client phone

Gender: Client gender Birthdate: Client birthdate

Highest Level of Education: Text field

Marital status: Client marital status

Race: Client race

Veteran: Client veteran status

 

Desired Move in Date: Date

What is your sober date:

Client sobriety date

Why did you chose to apply to live at Joyce's House? Paragraph

Medical History

Mental Health Diagnosis: Client diagnosis Health problems: Client health problems

Substance of Choice: Client substances of choice

Kinds of meetings attended: Client kinds of meetings attended

Allergies: Client allergies Last Date of Use: Client relapse date

Referred by: Client referred by Referral source: Client referral source

Do you receive food share?

 Checkboxes

Insurance Information:

Health Insurance: 

Checkboxes

 

 

Are you receiving W2, unemployment compensation, disability payments, worker's comp, alimony, VA benefits, or other income?

Checkboxes

Explain: Paragraph

 

How would you rate your personal health?

Checkboxes

 

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 JOYCE'S HOUSE?

Checkboxes

IF YES, PLEASE EXPLAIN:

Paragraph

 

Intake Coordinator notes:

Paragraph