New Vine Living - Admission Form

General Information 

Your Name: Client first name Client last name

Preferred name or Nickname: Client nickname

Date of Birth: Client birthdate

Gender: Client pronoun

Phone Number: Client phone

Email: Client email

Your Current Address: Client AddressClient CityClient StateClient Zip

Preferred Move In Date: Date

Do you have transportation or will you be using public transportation? Dropdown

Do you smoke? 

Checkboxes 

If yes, please explain. 

Text field

 

Employment Information

 EmploymentHistory

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 food restrictions?

Checkboxes

If yes, please explain. Text field

Do you need first floor accessibility or are you comfortable walking up stairs? Dropdown

 

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: Text field

Parole Officers Phone Number: Number field

Probation

 

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 urinalysis (drug screen) upon entry to the program? 

Checkboxes

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.