Iowa City Sober Living Intake Form
 

Iowa City Sober Living Intake

Welcome to the  Iowa City Sober Living intake wizard. Answer all questions honestly and as complete as possible. This form will be reviewed with you on admit. All information is kept secure and confidential.
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
 

Are you on Medicaid? Radio buttons

Are you receiving Food Stamps? Radio buttons

Do you believe you have a disability?  Radio buttons If yes, please explain: Text field

What is your gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran status
Desired date to move into ICSL: 
Text field
Do you have children?  
Child Welfare History
Family Members

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:  (mailing address after discharge) Text field
City:Text field
State:Text field
Zipcode:Text field

Contacts

Give us a few people that we can reach out to in case of an emergency. WE MUST HAVE AT LEAST ONE CONTACT PERSON WITH PHONE NUMBER and permission to contact.
Contact

Insurance

Enter your medical insurance provider(s). We will need a picture of your card on admit.
Insurance

Medical History

Tell us about your medical history.
When was your last relapse date?  When is your sobriety date--first day without alcohol or substance use .
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 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
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
 

Medications

List the medications you are currently prescribed. Please have all meds, prescribed and OTC available at admit.
Medication
 
 
 
 
 
 

Abuse History

Type of abuse: Text field Date started:   Date  Date ended: Date

Comments: Paragraph

Type of abuse: Text field Date started:   Date  Date ended: Date

Comments: Paragraph

Type of abuse: Text field Date started:   Date  Date ended: Date

Comments: Paragraph

Type of abuse: Text field Date started:   Date  Date ended: Date

Comments: Paragraph

Type of abuse: Text field Date started:   Date  Date ended: Date

Comments: Paragraph

 

 

 

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

Occupancy

 
What facility will you be staying at?
Iowa City Sober Living
What date will you be admitted on?
Client admit date
What is the estimated length of stay? Average is 6 months but can stay up to a year.
Client estimated length of stay
When will you be discharged?
Client discharge date

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. Where will you go if discharged unexpectedly from ICSL?
LivingArrangementHistory
City:Client City
State: Client State
 
 
When completed, please select Pending before hitting Submit
Client categories