Shoreline Recovery Application

Shoreline Recovery Application

 

 

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

Children: 

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If yes, how many and what are their ages? Text field

Gender: Client genderTreatment center 1 started

Veteran: Client veteran status

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Treatment Experience

 

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

 

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Recovery & Sober Living Experience

 

Sobriety/Clean Date: Recovery history 1 sobriety date

List Alcohol & Drugs of Abuse: Client substances of choice

Requested Move-In Date: Sober living 1 admitted

 

Prior Sober Living Experience: 

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Name of Sober House:  Sober living 2 name

Date Admitted: Sober living 2 admitted

Length of Stay: Sober living 2 estimated length of stay

Reason for Leaving: Sober living 2 reason for discharge

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Emergency Contact Information:

 

Contact #1

Name: Contact 1 name

Phone: Contact 1 phone

Contact 1 type

Email Address: Contact 1 email

 

Contact #2

Name: Contact 2 name

Phone: Contact 2 phone

Contact 2 type

Email Address: Contact 2 email

____________________________________________________________________________________________________________________________________

 

List of Current Medications: 

 

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

 

Allergies: 

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If so, what are you allergic to? Client allergies

 

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Employment & Education


Are you employed? 

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If yes, who is your employer? Text field

If no, what job plans do you have? Text field

What is your monthly income right now? Employment 1 income

Are you in School: 

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Highest level of education completed: Dropdown

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Legal

 

Do you currently have any pending legal cases? 

Checkboxes

If Yes, what are you charged with? Text field

 

Are you currently on probation or parole? 

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If Yes, what are you convicted of? Text field

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Medical & Psychiatric

 

Do you have a medical doctor? 

Checkboxes

If yes, 

Name: 

Telephone Number:

 

Current medical conditions? 

Text field

 

Do you have a mental health medication prescriber? 

Checkboxes

If yes, 

Name:

Telephone Number:

 

Do you have a mental health counselor? 

If yes, 

Name:

Telephone Number:

 

Psychiatric History:

Have you been diagnosed with or treated for:

Bipolar disorder 

Checkboxes

 Depression 

Checkboxes

Post-traumatic stress 

Checkboxes

Anxiety 

Checkboxes

Schizophrenia 

Checkboxes

Schizoaffective 

Checkboxes

Alcohol abuse 

Checkboxes

Anger 

Checkboxes

Other substance abuse 

Checkboxes

Suicide 

Checkboxes

Violence 

Checkboxes

 

 ____________________________________________________________________________________________________________________________________

 

Medical Insurance

 

Insurance Provider: Client insurance provider

Group ID: Client insurance group ID

Policy Number: Client insurance policy #

Primary on Insurance: Client insurance other

 

 

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

Date: Date