Date: Date
Name: Client first nameClient last name
Date of Birth: Client birthdate
Phone Contact: Client phone
Sex: Client gender
Describe your current living situation:
Paragraph
Drug of choice and last used when:
Client substances of choice Text field
How many years have you been using alcohol and/or drugs: Text field
Do you have any physical health/medical conditions or disabilities:
Are you currently using any prescription medications?
Medication
Do you have any previous felonies or misdemeanors. Please also list any ongoing legal issues:
Are you able to be employed for at least 31 hours weekly, make recovery meetings, and participate in household chores: Text field