Comeback Recovery Homes Application
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General
Tell us about yourself.
What is your first name? Client first name
What is your last name? Client last name
What name do you go by if other than your legal first name? Client nickname
When is your birthdate? Client birthdate
What is your race/ethnicity? Client race
What is your gender? Client gender
What is your marital status? Client marital status
Are you a veteran? Client veteran status
Are you on probation or parole? Dropdown Start Date: Date End Date: Date
Probation/Parole officer name and contact information: Text field
Are you enrolled in food stamps? Dropdown
Do you need assistance enrolling in food stamps? Dropdown
Do you have a permanent address? Dropdown
What type of address is your permanent address? Dropdown
Are you currently employed? Dropdown
How much is your current annual income? (No income is not a disqualification for being considered for the home.) Text field
Are you on Medicaid? Dropdown
Anything else we need to know?
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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
Permanent or forwarding address: Client Address
City: Client City
State: Client State
Zip: 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? Date
What is your date of sobriety? 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
If you have a sponsor, please provide their name and contact information? Text field
What allergies do you have? List meds and foods. (No allergies? Move on to the next question.)
Client allergies
Are you under the care of a therapist or other clinician? Dropdown
Medications
List all medications, prescription and over the counter, that you are currently taking. Include dosage and frequency if known.
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Treatment Centers
Tell us about any treatment centers you've previously been admitted into.
TreatmentCenterHistory
Client Referral Source
How did you hear about us?
Client Referred By
Text field
Occupancy
What date would you like to move in? Date
What is the estimated length of stay? Client estimated length of stay
When will you be discharged from treatment? 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", and type "none" in the fields.
EmploymentHistory
Living Arrangements
Tell us about your living arrangements prior to moving into this facility.
LivingArrangementHistory