Allos Ministries Intake Application
Welcome to the Sober Homes intake wizard
Click next to begin!
General
Tell us about yourself
What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
When is your birthdate?
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
Which Opportunity Home are you applyng for?
Client facility
Social Security Number
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?
Recovery history 1 relapse date
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
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 Opportunity Home are you applying for?
Client facility
What date would you like to move in?
Client admit date
What is the estimated length of stay?
Client estimated length of stay
When will the 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
Text field
Probation
Brief Biography:
“Write a brief biography of your life, where you were born, how you were raised, where you have been, why you are here now, and your plans for the future. Also include your spiritual experiences.”
Paragraph
Sex Offender Status
•Have you ever been classified as a sex offender under Minnesota Law? Radio buttons
•Or any other state? Radio buttons
•Explain: Paragraph
Motivation
•Why are you interested in being a part of the Allos home? Paragraph
Employment & Financial Information
•Are you working? Checkboxes
•If yes, where? Text field
•Hours/week:Text field
•Supervisor name & phone:Text field
•Monthly income:Text field
•How long employed?Text field
•Other income (checkboxes + dollar amounts):Text field
•Social Security: Text field
•Disability: Text field
•Retirement: Text field
•Un-earned income: Text field
•Assistance received (checkboxes + county field): Text field
•General Assistance: Text field
•Medical Assistance: Text field
•Food Stamps: Text field
•Have you applied for assistance? Text field
Assets
•Cash, checking/savings accounts, 401(k), 403(b), stocks, IRA, mutual funds, bonds, personal property, tools of trade, life insurance, burial accounts, trust funds, real estate/home ownership
•Have you transferred any property in the last 36 months? Text field
Vehicles
•Do you have any vehicles? If yes:
•How many? Text field
•Make & Model(s): Text field
•Estimated Value(s): Text field
Debts
•Student loans Checkboxes $ Text field
•Credit cards Checkboxes $ Text field
•Personal loans Checkboxes $ Text field
•Medical bills Checkboxes $ Text field
•Vehicle loans Checkboxes $ Text field
•Mortgage Checkboxes $ Text field
•Fines/court costs Checkboxes $ Text field
•Restitution Checkboxes $ Text field
•Co-signed loans Checkboxes $Text field
•Child support (current and back) Checkboxes $Text field
•Other debts Checkboxes $ Text field
Legal Situation
•Current legal status: Text field
•On probation/parole? Checkboxes
•Pending court cases? Checkboxes
•Under investigation? Checkboxes
•Lawsuits? Checkboxes
•Court-ordered community service? Checkboxes
•Ordered to pay restitution/fines/child support? Checkboxes
•Probation officer name/contact: Text field
•Next court date: Date
•What county? Text field
•Past legal history (checkboxes + explanation): Checkboxes Paragraph
•Arrests: Checkboxes
•Jail/prison history: Checkboxes
•Juvenile detention: Checkboxes
•Prior probation/parole: Checkboxes
Criminal Activity: Checkboxes
Tobacco Use
•Do you use tobacco? Radio buttons
•If yes: Checkboxes