Personal Information: 

This application should be filled out to the best of your ability. If you do not know the answer skip it and we can call you.

Date:Date  Referred By:Client Referred By

Name:Client first nameClient last name  Currently Pregnant?Dropdown

Date of Birth:Date Age:Text field

Current Address:Client Address

 Best Contact Number:Client phone   Drivers license number:Text field

Vehicle: (Year, Make, Model & License Plate number) Text field

Sobriety Date:RecoveryHistory   Length of Use:Text field

Drug of Choice:Text field  Date last used:Date  Will your UA be clean if voted in?Dropdown 

If no, what will UA be postive for?Text field

Prior Treatment, Sober Living, Detox or Mental Health Counseling:TreatmentCenterHistoryParagraph

RX/OTC Medication (pill count is not necessary):Medication

Reason for Medication:Text field

Medical Conditions/Diagnosis:Client diagnosis

Employment or Prior Education:

School/former School:EducationHistory Client school  Description or Major:Text field

Employer:EmploymentHistory Employed for how long:Text field Monthly Income:Text field

Are you able to pay move in costs? If not, what is your plan?:Paragraph

Family Information:

Marital Status:Client marital statusText field

Children:Family Members Age:Text field

Who do your children live with and is there a custody agreement in place?:Client categories

Emergency Contact:

Name:Contact  Relationship:Text field

Legal Information:

Arrests:Criminal History Drug or Alcohol related?:Text field DUI:Text field

Probation or Parole Officer:Probation  Will you need to appear in court while living at Soaring Heights Recovery Homes?:Dropdown

Have you ever registered as a sex offender?Dropdown

Have you ever been convicted of a violent crime?Dropdown

Is there a no-contact order or restraining order against you or filed against someone else?:Text field

If so with who:Text field

Current Charges or Convictions:Text field

I certify that the facts set forth in this application are true and complete, to the best of my knowledge.

SignatureDate

Witness (if applicable):SignatureDate

 

For staff use only:

House Name:Client facility

Voted in?:Text field

Client notes

Client notes

Client medical notes