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
Requested Move-In Date: Sober living 1 admitted
Prior Sober Living Experience:
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
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 no, 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
Do you have a medical doctor?
Current medical conditions?
Do you have a mental health medication prescriber?
Do you have a mental health counselor?
Have you been diagnosed with or treated for:
Other substance abuse
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