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:Text field Pregnant?Dropdown Date of Birth:Date
Age:Text field Cell Phone:Client phone
Current Address:Client Address Do you have a valid ODL#Text field
Do you have valid insurance?Dropdown
Vehicle: (Year, Make, Model & License Plate) Text field
Sobriety Date:Text field
Length of Use:Text field Date last used:Text field
Drug of Choice:Client substances of choice
Will your UA be clean if voted in?Checkboxes
If no, what will your UA be positive for? Text field
Are you attending any recovery based meetings?Text field
Prior Treatment, Sober Living, Detox or Mental Health Counseling:Text field
RX/OTC Medication (pill count is not necessary):Text field
Reason for Medication:Text field
Medical Conditions/Diagnosis:Client diagnosis
Have you ever lived at Soaring Heights?Checkboxes
When and why did you leave? Text field
Employment or Prior Education:
School/former School: Client school
If not, are you ready to work?Text field
Employer:Text field Employed for how long:Text field
Monthly Income:Text field
Family Information:
Marital Status:Client marital statusText field
How many children do you have:Text field Ages:Text field
Who do your children live with and is there a custody agreement in place?:Text field
Emergency Contact:
Name:Contact
Legal Information:
Arrests:Criminal History Drug related?:Dropdown Alcohol related:Dropdown
Probation or Parole Officer:Text field
Will you need to appear in court while living at Soaring Heights Recovery Homes?:Text field
Have you ever registered as a sex offender?Text field
Have you ever been convicted of a violent crime?Text field
Is there a no-contact or restraining order against you or against someone else?:Text field
If so with who:Text field
Current Charges or Past 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