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
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?
Are you receiving W2, unemployment compensation, disability payments, worker's comp, alimony, VA benefits, or other income?
How would you rate your personal health?
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?
IF YES, PLEASE EXPLAIN:
Intake Coordinator notes: