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

Pregnant?Dropdown Date of Birth:Client birthdate

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