1. Application

 

 Redemption Recovery Institute Application

Welcome to the Redemption Recovery Institute intake wizard
Click next to begin!

General

Tell us about yourself
What is your first name?
Client first 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
Do you have a treatment provider? If yes, who.
Client notes

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

Emergency Contacts

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

Substance Abuse 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 a Mental Disorder Add multiple by clicking in the box and selecting different options
Client diagnosis
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended

Client Referral Source

 
Who referred you to us?
Client Referred By

Sober Living History

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