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
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?
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Criminal History
Have you ever been arrested?
Dropdown
If yes, please provide charges and approximate dates:
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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:
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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.
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Please list all health professionals you are currently seeing. (primary care, psychiatry, therapy, counseling)
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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?
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Are you open to pursuing a spiritual path of recovery using the 12 steps and biblical principles?
Dropdown
If no, please explain.
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Other than sobriety, what are three things you hope to get out of your stay at Dynamic Life?
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Tell us why you believe Dynamic Life is a good fit for you.
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Medications
List the medications you are currently prescribed.
Medication