First Name: Client first name
Middle Name: Client middle name
Last Name: Client last name
Driver’s License (state & number): Text field
Email: Client email
Mobile Number: Client phone
Date of Birth: Client birthdate
Age: Text field
Marital status: Client marital status
If yes, how many and what are their ages? Text field
Gender: Client genderTreatment center 1 started
Veteran: Client veteran status
Are you currently in treatment?
If yes, where? Treatment center 1 name
Type of program:Treatment center 1 type
Clinician Name: Treatment center 1 notes
Clinician email address: Treatment center 1 address
Clinician telephone number: Treatment center 1 name
Admission date: Treatment center 1 started
Expected discharge date:Treatment center 1 ended
Sobriety/Clean Date: Recovery history 1 sobriety date
List Alcohol & Drugs of Abuse: Client substances of choice
If admitted, what is your requested move-in date to a Shoreline Recovery home: Client admit date
Please tell us about your recovery history (to include past successes and obstacles to maintain sobriety):
Have you ever lived in a sober house before?:
Name of Sober House: SoberLivingHistory
Name: Contact 1 name
Phone: Contact 1 phone
Contact 1 type
Email Address: Contact 1 email
Name: Contact 2 name
Phone: Contact 2 phone
Contact 2 type
Email Address: Contact 2 email
List Psychiatric Medications First
Medication #1 Medication 1 name
Medication #2 Medication 2 name
Medication #3 Medication 3 name
Medication #4 Medication 4 name
Medication #5 Medication 5 name
Medication #6 Medication 6 name
Other Medications: Medication 7 name
If so, what are you allergic to? Client allergies
Are you employed?
If yes, who is your employer? Text field
If not, what job plans do you have? Text field
What is your monthly income right now? Employment 1 income
Are you in School:
Highest level of education completed: Dropdown
Do you currently have any pending legal cases?
If Yes, what are you charged with? Text field
Are you currently on probation or parole?
If Yes, what are you convicted of? Text field
Have you ever been convicted of a felony?
If yes, what were you convicted of, and in what year did the conviction occur? Text field
Are you currently on the sex offender registry?
Do you have a medical doctor?
If yes, Text field
Name: Text field
Telephone Number:Text field
Current medical conditions?
Do you have a mental health medication prescriber?
Do you have a mental health counselor? Checkboxes
Telephone Number: Text field
Have you been diagnosed with or treated for:
Obsessive-Compulsive Disorder (OCD)
In order to move into a Shoreline recovery residence you must be vaccinated and boosted or willing to get vaccinated within one day of moving in.
Have you been vaccinated against COVID? Checkboxes
If yes, what are the dates of your vaccinations Date Date Boosters? Date Date
If you haven't received the booster, you will be required to do so to live at Shoreline.
Statement of Perjury
It is important that the information you give us is true and that you understand what happens if you are not giving truthful information on this form. You may be punished by fine or imprisonment or both (18 U.S.C. 1001). To indicate you have read and understand the above, please certify below:
I, Text field, hereby certify that the answers I provided above are truthful.
Text field (Signature) Date (Today’s date)
Insurance Provider: Client insurance provider
Group ID: Client insurance group ID
Policy Number: Client insurance policy #
Primary on Insurance: Client insurance other
Who will be responsible for paying your residential fees and living expenses if you are accepted into Shoreline Recovery?
Name: Contact 3 name
Relationship: Text field
Telephone: Contact 3 phone
Email Address: Contact 3 email
By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.
Resident Signature: Signature