Aggate Recovery Residence Intake Form

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AGGATE RECOVERY RESIDENCE 

 

Standing at the start of a new chapter in recovery, you deserve a supportive, empowering environment to nurture your sobriety. Here at the Aggate Recovery Residences, we're more than just a housing provider – we're your trusted partner in achieving a life enriched by recovery. We understand the unique challenges you face, and we're dedicated to creating a welcoming, structured space where you can cultivate lasting well-being, build meaningful connections, and rediscover your potential.

Our commitment to your success starts with understanding your needs. While HIPAA regulations ensure the utmost privacy and confidentiality of your information, knowing a little about your background and circumstances allows us to tailor our support to perfectly fit your journey. Think of it as opening the door to a personalized roadmap for thriving in sobriety. We'll never ask for anything beyond what's essential to provide the most optimal environment for your growth and comfort.

So, take a deep breath and step into the vibrant community of Aggate Recovery Residences. Here, you'll find a network of fellow travelers walking similar paths, offering encouragement and shared experiences. Our dedicated staff, seasoned in supporting recovery, provides guidance and resources without judgment, fostering a safe space where you can truly be yourself.

Ready to write a new chapter of strength and connection? Let's embark on this empowering journey together. We'll walk alongside you every step of the way, ensuring your privacy and confidentiality while building a haven for your continued sobriety.

Entrance into the Aggate Recovery Residences require the downloading of the One Step Application


Welcome to the AGGATE RECOVERY RESIDENCE Intake Wizard
Click Next to Begin!

Personal information 

Tell us about yourself

Please complete all Questions Below 


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
What is your birthdate?
Client birthdate
last 4 digits of your social security number
SSN
What is your Monthly Gross Income, 
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What is your Monthly General Assistance
Paragraph
What is your Monthly Food stamps
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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
Tell us about yourself, what you like and do not like 
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YOUR Contact Information

Please complete all Questions Below 


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
Zip code:
Client Zip

 Important Contacts


EMERGENCY 

Contact

 Sober Sponsor

Contact

 Certified Peer Recovery Specialaist

Contact

Probation

Contact

Parole

Contact

Medical Insurance

Enter your insurance provider(s).

Insurance

Medical History

Tell us about your medical history.

What is your sober date 
Date
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 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
 
Vaccinations
Vaccines
 

Medications

List the medications you are currently prescribed.

Medication
 
 

Treatment Centers


Current Treatment Center

Tell us about the treatment center you are attending

TreatmentCenterHistory

Counselor Name, Email, Phone Number 

Contact

 

Client Referral Source

 

Who referred you to us?
Client Referred By
 

Occupancy

 

 

Estimated length of stay?

Client estimated length of stay

Estimated discharge date?

Client discharge date

Sober Living History

Tell us about any sober living 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

After Treatmant Graduation where would you like to move to 


LivingArrangementHistory
 
 

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.

 Client Signature

Signature   Signature date Date