Application for Admittance to River City Recovery Ministries

Name:Client first nameClient middle nameClient last name

Contact Information:Client phoneClient email

Current Address:Client AddressClient CityClient StateClient Zip

Current treatment facility and counsleor contact info:Text field

Race*:Client race

Birthdate:Client birthdate

Age:Text field

Where you were raised:Text field

Previous inpatient recovery attempt:Text field

How many completed:Text field

Drug of choice:Client substances of choice

Others used:Text field

Current Medications:Medication

Mental Health Diagnosis:Client diagnosis

Physical Health Status:Client health problems

Emergency Contact:Contact

Family Members:Family Members

Children:Child Welfare History

Criminal History:Criminal History

Parole/Probation:Probation

Probation agent:Text field

Agent contact info:Text field

Please Note: River City Recovery is not resposible for lost or stolen property. We strongly recommend that residents secure valuables and money so that they are not accessable to others.

By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.

Signature

Date