Thank you for your interest in Phoenix Recovery!  All questions must be answered.  If a question does not apply to use please put NA.  We look forward to speaking soon!

 

Client first name  Client last name  

Birthday: Client birthdate  

Client phone

Client email

Contact:

Current Location: Text field

Expected Discharge Date: Text field

Case Manager Name: Text field

Case Manager Phone Number: Text field

Case Manager Email Address: Text field

Emergency Contact Name: Text field

Emergency Contact Phone Number: Text field

Demographics:

Sex at Birth: Dropdown

Gender Identity: Dropdown

Preferred Pronouns: Dropdown

What is your primary language? Text field

Family:

Are you fleeing a domestic violence situation? Dropdown

Do you have minor children? Dropdown

What is your minor children(s) current living arrangement? Paragraph

Are your minor children safe? Dropdown

Is there DCS involvement? Dropdown

If so, what is required of your parenting plan? Paragraph

Substance Use History:

Substance(s) of Choice: Checkboxes

How long have you been using alcohol and/or drugs? Text field

What is your sobriety date? Date

Medical:

List any allergies: Paragraph

How would you describe your current health? Dropdown

Please explain any concerns you have about your current health: Paragraph

Do you have any chronic medical (physical) conditions or disabilities that interfere with your day-to-day tasks? Paragraph

Do you have a history of seizures? Dropdown

List any medical equipment or aids: Paragraph

Mental Health:

List any mental health diagnoses and when you received each diagnosis: Paragraph

Please describe any history of self-harm: Paragraph

Please describe any history of suicidal ideation, attempts, or inpatient psychiatric stays: Paragraph

Please describe any history of disordered eating: Paragraph

Describe any involvement with violent and/or aggressive behaviors: Paragraph

Medication:

Please list all prescription medication(s): Paragraph

Please list all over-the-counter medication(s) that are taken regularly: Paragraph

Please list any drug replacement (MAT/MAR/MOUD) medication(s): Paragraph 

Treatment History:

Please list all previous treatment center(s) and date(s): Paragraph

Courts & Criminal Justice:

Are you currently involved in any legal proceedings or criminal justice issues? Dropdown

Do you have any pending sentencing or possible jail time upcoming? Dropdown

Have you ever been charged or convicted of arson? Dropdown

Have you ever been charged or convicted of any violent crimes in any jurisdiction? Dropdown

Have you ever been charged or convicted of abuse or neglect of any person, including but not limited to disabled persons, seniors, or children? Dropdown

Are you required to register as a sex offender? Dropdown

Are there any restraining orders or orders of protection against you or by you? Dropdown

Admissions:

Do you have a personal relationship with anyone who works for Phoenix Recovery? Dropdown

      If so, who and what is the nature of the relationship? Paragraph

Do you know anyone currently in the Phoenix Recovery program? Dropdown

      If so, who and what is the nature of the relationship? Paragraph

Have you previously been a client at Phoenix Recovery? Dropdown

Client Statement:

Please describe what led you to seek housing at Phoenix Recovery: Paragraph

What do you want to accomplish while residing at Phoenix Recovery: Paragraph

Will you be attending outpatient treatment while at Phoenix Recovery? Dropdown

      If so, what level of treatment (Dropdown) and where? Text field 

Do you receive SSI or SSD? Dropdown

Are you currently employed? Dropdown

Are you able to work at least 32 hours a week? Dropdown

Additional Info:

Please enter any other information about yourself or your situation that you feel we need to know:

 

Signature  Date