intake form

 

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Dads With A Purpose intake form

Welcome to the Dads With A Purpose intake wizard
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 gender?
Client gender
 
Do you receive social security disability benefits?Text field
If yes, when is your next sheduled payment?Text field
Have you ever been convicted of a sex crime?Dropdown

Are you on Probation/ParoleText field

Witch county are you on probation out of?Text field

Po NameText field

Po Email address:Text field

PO phone numberText field

What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attendedDropdown
Sponsor Name:Text field
Sponsor Contact Information:Text field


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:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip

Contacts

Give us a few people that we can reach out to in case of an emergency.
Contact

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 any health problems? Add multiple by clicking in the box and selecting different options
Client health problemsText field
What allergies do you have? No allergies? Move on to the next question.
Client allergies
 

Medications

List the medications you are currently prescribed.
Medication

Treatment Centers

Tell us about your most reacent  treatment center you attended  in the last 90 Days
TreatmentCenterHistory

 

 

Employment 

Are you currently employedCheckboxes

Sober Living History

Tell us about any sober livings you've previously been admitted into.
SoberLivingHistory

 

 


Living Arrangement

Tell us about your living arrangement prior to moving into this facility
LivingArrangementHistory

Referral Source 

Who can we thank for reffering you to our program?Checkboxes Text field