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
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?
Paragraph
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
In connection with your residency application with Dynamic Life Recovery Community, this notice is intended to inform you that upon acceptance into our program, a consumer report will be obtained on you from a consumer reporting agency for residency purposes. The report may contain information about you relating to your criminal information or history, driving and/or motor vehicle records, verification of your education or employment history, social media or other background checks.
I acknowledge and understand that my acceptance into the Dynamic Life Recovery Community is contingent upon the results of a background check. While Dynamic Life Recovery Community does not deny residency solely based on background screenings, the following factors are taken into consideration:
I also acknowledge and understand that this background check will not be conducted unless I am accepted into the program, and I am financially responsible for the cost of the background check. A fee of $25 is required and will be paid at intake. If payment is not made at that time, the fee will be charged to my account and must be paid as soon as possible.
I certify my answers to be true and correct to the best of my knowledge. If approved to participate in this program, I understand that any false or misleading information in my application or interview may result in my discharge. I give authority to Dynamic Life Recovery to obtain information as it relates to this application and for my recovery as a resident in this program. Dynamic Life follows all federal/state/local laws regarding non-discrimination, fair houseing act, and Americans with Disabilities Act.
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.