Application

  

 

Sober Homes Intake

Welcome to the Sober Homes intake wizard
Click next to begin!

General

Tell us about yourself
What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your race/ethnicity (if you would like to share)?
Client race
What is your gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran status

Please list all convictions and date of convictions – anything on criminal record

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Are you currently on probation or parole? Y/N Text field

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

Contacts

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

Insurance

Enter your insurance provider(s).
Insurance

Medical History

Tell us about your medical history.
Do you think you have a problem with drugs/alcohol? Y/N/Unsure
Text field 
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 anything? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
Do you have a history of overdose? Y/N ________
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
What allergies do you have? No allergies? Move on to the next question.
Client allergies

Please list all doctor-prescribed medications you are currently taking. Are you currently prescribed any of the narcotics below? Adderall, Buprenorphine, Codeine, Hydrocodone, Methadone, Suboxone, Tramadol, and others?

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Have you had any of the following tests?

Medical Tests
 

Medications

List the medications you are currently prescribed.
Medication

Treatment Centers

Tell us about any treatment centers you've previously been admitted into.
TreatmentCenterHistory

Client Referral Source

Who referred you to us?
Client Referred By

Occupancy

What facility will you be staying at?
Client facility
What date will the you be admitted on?
Client admit date
What is the estimated length of stay?
Client estimated length of stay
When will the you be discharged?
Client discharge date

Sober Living History

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

 

SoberLivingHistory

Are you currently working or willing to work on a recovery program? (AA, NA, CA, etc.)Text field

What is your vision for success while participating in Texas Recovery Residences Programs?

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Employment
Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"

EmploymentHistory

Do you have a vehicle? Y/N Radio buttons

Are you currently employed? Y/N Radio buttons

Where do you work? Text field

Living Arrangement

Tell us about your living arrangement prior to moving into this facility
LivingArrangementHistory
 
Are there any warrants out for your arrest? Y/N Radio buttons