New Vine Living - Admission Form
General Information
Your Name: Client first name Client last name
Preferred name or Nickname: Client nickname
Phone Number: Client phone
Email: Client email
Date of Birth: Client birthdate
Your Address: Client AddressClient CityClient StateClient Zip
Preferred Move In Date: Date
Secured Information
Social Secutiry Number: SSN
Driver's License/State ID# Text field
Military ID: Text field
Marital Status: Client marital status
Financial Information
What is your monthly income? Number field
Second form of income: Number field
Available Savings: Number field
Your monthly expenses (total monthly expenses including cell phone, car loans, insurance, etc.): Number field
Emergency Contact #1 Information
Contact
Medical Information
Insurances
Do you have any allergies?
Checkboxes
If yes, please specify. Client allergies
Do you have any medical conditions: Client health problems
Please describe any history of mental health issues or diagnoses: Client diagnosis Paragraph
Do you have any special medical equipment?
Checkboxes
If yes, please specify. Text field
Have you been exposed to COVID-10 in the past 5 days?
Checkboxes
Are you experiencing any flu like symptoms? (Cough, fever, etc.)
Checkboxes
Do you have regular medical appointments?
Checkboxes
if yes, please explain. Paragraph
Do you have any food restrictions?
Checkboxes
If yes, please explain. Paragraph
Do you need first floor accessibility or are you comfortable walking up stairs? Dropdown
Is there anything else we should know regarding your health? Paragraph
Medications:
Please list any medications you take whether prescribed or over the counter.
Medication
Criminal History:
Criminal History
If yes, please provide details. Paragraph
Are you on probation or parole?
Checkboxes
If yes, please provide your parole officer's contact information below.
Parole Officers Name: Client first nameClient last name
Parole Officers Phone Number: Client phone
Probation
Resident Suitability Questionnaire
Can you walk independently?
Checkboxes
Can you participate in household cleaning and chores?
Checkboxes
Do you bathe everyday?
Checkboxes
Can you get dressed on your own?
Checkboxes
Do you have issues with bladder control?
Checkboxes
Do you have transportation or will you be using public transportation? Dropdown
Do you smoke?
Checkboxes If yes, please explain. Text field
What time do you normally go to bed?Text field
List your favorite foods. Paragraph
What activities do you enjoy? Paragraph
List any concerns you may have living with a roommate. Paragraph
Do you work or volunteer anywhere? Paragraph
Please list anything else we should be aware or concerned about. Paragraph
Sobriety Information
Are you recovering from any addiction we should be aware of?
Checkboxes
If yes, please answer the following questions:
What is your substance of choice? Client substances of choice
RecoveryHistory
Do you have a sponsor? Client sponsor
Which meeting do you attend? Client kinds of meetings attended
Will you be able to submit a negative UA drug screen upon entry of our program?
Checkboxes
*A clean UA will be required upon entry of our program and random UA's will be required in order to continue participation*
Have you lived in a sober home previously?
SoberLivingHistory
Referral Information
*If you are not being referred, please leave blank*
Who are you being reffered by?
Name of referral person: Text field
Name of referring agency: Text field
Please read before submitting:
I understand that my application will be carefully reviewed and that acceptance into New Vine Living is not guaranteed. I am fully committed to following the house rules and expectations of the home, actively participating in the community, and maintaining a sober lifestyle.
By submitting this application, I acknowledge that I am responsible for reading, understanding, and adhering to all house rules provided by New Vine Living. I understand that compliance with these rules is a condition of residency, and failure to follow them may result in dismissal from the program.
Checkboxes
I affirm that all information I provide during the intake and admissions process will be truthful, complete, and accurate. I acknowledge that providing false, misleading, or incomplete information—whether spoken or written—may result in denial of admission or immediate dismissal from the program.
If you have any questions or need additional information, please feel free to contact us at 860-981-0557 or info@newvineliving.com.
Sign here:
Signature
Your printed name: Text field
Today's Date: Date
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.