"Where transformation begins..." 

Application Form 

Welcome to The House of Living Water, Inc. intake wizard
Click next to begin!

 

 

 

 

General

Tell us about yourself

What is your first name?
Client first name
What is your middle name? 
Client middle name
What is your last name?
Client last name
What is your pronoun?
Client pronoun
What is your birthday?

Client birthdate

What is your race/ethnicity?
Client race

What is your gender?
Client gender

What is your marital status?
Client marital status

Are you a veteran?
Client veteran status
Facility? 
Client facility
 
SSN 
SSN

 

 

 

 

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:Client Address

City:Client City

State:Client State

Zipcode:Client Zip

 
Family Members

 

 

 

 

Contacts

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

Contact

 

 

 

Insurance

Enter your insurance provider(s).

Insurances

 

 

 

Medical History

Tell us about your medical history.

When was your last relapse date? 

RecoveryHistory

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
Have you had any of the following tests?

Medical Tests
 
Vaccines 

 

 
 

Medications

List the medications you are currently prescribed.

Medication 

 

 

Treatment Centers

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

TreatmentCenterHistory 

 

 

 Client Referral Source

Who referred you to us?

Client Referred By 

 

 

Occupancy

What facility will you be staying at?

Client facility

What date will you be admitted on?

Date

What is the estimated length of stay?

Client estimated length of stay

When will you be discharged?
Client discharge date 

 

 

Sober Living History

Tell us about any sober livings you've previously been admitted into.

SoberLivingHistory 

 

 

Employment & Education

Tell us about your employment status.

If you're currently unemployed select "unemployed" under "type"

EmploymentHistory

 
EducationHistory 

 

 

Living Arrangement

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

LivingArrangementHistory 

 

 

 

Any Additional Notes

Client notes

Probation