Dynamic Life Recovery Application

 Dynamic Life

 

Dynamic Life Recovery Intake


Welcome to the Dynamic Life Recovery Application
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?
Client race
What is your gender?
Dropdown
What is your marital status?
Client marital status
Are you a veteran?
Client veteran status

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

Addtional information

Do you have children? If yes, please list them. If no, please type "None".

Text field

Do you have a valid dirver's license?

Dropdown

Do you have a state ID?

Dropdown

Do you have your social security card?

Dropdown

Are you able to work?

Dropdown

Are you disabled?

Dropdown

What was your last job, how long were you there, and reason for leaving?

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What is your financial plan to pay the $200 weekly program fee?

Paragraph

 

Criminal History

Have you ever been arrested?

Dropdown

If yes, please provide charges and approximate dates:

Paragraph

Have you been convicted of a sex crime?

Dropdown

Are you court ordered to reside in a sober home?

Dropdown

Do you currently have any active warrents in any state in the United States?

Dropdown

Do you have any pending charges or upcoming courtdates?

Dropdown

If yes, please explain:

Paragraph

 

Insurance

Enter your insurance provider(s).

Insurance

Medical History

Tell us about your medical history.

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 a history of suicidal/Homicidal, or self-harm tendencies? 
Dropdown
If yes, Please explain.
Paragraph
Please list all health professionals you are currently seeing. (primary care, psychiatry, therapy, counseling)
Paragraph
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
Do you have a 12 step sponsor?
Dropdown
What allergies do you have? No allergies? Move on to the next question.
Client allergies

Have you had any of the following tests?

Medical Tests
 

Spiritual History

Who or what would you say your Higher Power is?

Text field

Have you atteneded church in the last 5 years?

Dropdown

If so, where have you attended?

Paragraph

Are you open to pursuing a spiritual path of recovery using the 12 steps and biblical principles?

Dropdown

If no, please explain.
Paragraph

Other than sobriety, what are three things you hope to get out of your stay at Dynamic Life?

Paragraph

Tell us why you believe Dynamic Life is a good fit for you.

Paragraph

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

Sober Living History

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

SoberLivingHistory

Employment

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

EmploymentHistory

Living Arrangement

Tell us about your living arrangement prior to moving into this facility

LivingArrangementHistory