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
When is the last date you used? 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
Allergies: Client allergies
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