One Step

Acceptance Sober Living Intake

Welcome to the Acceptance Sober Living intake wizard

Click next to begin!

General

Tell us about yourself

What is your first name?

What is your middle name? No middle name? Move on to the next question.

What is your last name?

When is your birthdate?

What is your social security number?

What is your race/ethnicity?

What is your gender?

What is your marital status?

Are you a veteran?

Contact Information

How can we reach you?

What is your email address?

At what phone number can we best reach you at?

What is your current drivers license number?

*Clients are required to have current driver's license, current registration and auto insurance if they will be operating a motor vehicle at Acceptance Sober Living.

Street Address:

City:

State:

Zipcode:

Contacts

Give us a few people that we can reach out to in case of an emergency. Include best phone number to contact.

Contact One

Contact #1
name:
phone:
email:
type:
Contact typeDon't see the option you're looking for? Click here
notes:

Relation to client

Contact Two

Contact #1
name:
phone:
email:
type:
Contact typeDon't see the option you're looking for? Click here
notes:
consent:
Choose option...Don't see the option you're looking for? Click here

Relation to client

Contact Three

Contact #1
name:
phone:
email:
type:
Contact typeDon't see the option you're looking for? Click here
notes:
consent:
Choose option...Don't see the option you're looking for? Click here

Relation to client

Health/Medical Insurance

Enter your insurance provider(s) and policy numbers.

Insurance #1
Client insurance provider:
Client insurance plan:
Client insurance group ID:
Client insurance policy #:
Client insurance other:

Medical History

Tell us about your medical history.

When was your last relapse date?

What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options

Substances of choice

Have you been clinically diagnosed with any mental health conditions? Add multiple by clicking in the box and selecting different options

Diagnosis

Do you have any health problems? Add multiple by clicking in the box and selecting different options

Health Problems

What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options

Substances of choice

Do you have any allergies? No allergies? Move on to the next question.

Have you had any of the following tests?

Medical Tests #1
type:
TypeDon't see the option you're looking for? Click here
performed_on:
notes:
result:
ResultDon't see the option you're looking for? Click here

Medications

List the medications you are currently prescribed.

Medication #1
Name:
Dosage:
Quantity:
Category:
Choose category...Don't see the option you're looking for? Click here
Frequency:
Md:
Notes:
Pill count:
Discontinued at:

Treatment Centers

Tell us about any treatment centers you've previously been admitted into.

Treatment Center History #1
name:
address:
city:
state:
zip:
started:
ended:
notes:
type:
Treatment center typeDon't see the option you're looking for? Click here
reason for discharge:
Treatment center reason for dischargeDon't see the option you're looking for? Click here

Client Referral Source

How did you hear about Acceptance Sober Living?

If you were referred, who referred you to us?

Occupancy

What facility will you be staying at?

What date will the you be admitted on?

What is the estimated length of stay?

*Acceptance Sober Living requires a minimum commitment of six months.

When will the you be discharged?

Sober Living History

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

Sober Living History #1
name:
description:
address:
city:
state:
zip code:
admitted:
discharged:
estimated length of stay:
reason for discharge:
Sober living reason for dischargeDon't see the option you're looking for? Click here

Employment

Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"

Employment History #1
Employer name:
Employment position:
Employment income:
Employment incomeDon't see the option you're looking for? Click here
Employment started:
Employment ended:
Employment type:
Employment typeDon't see the option you're looking for? Click here
Employment notes:

Living Arrangement

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

Living Arrangement History #1
arrangement:
Living arrangementDon't see the option you're looking for? Click here
started:
ended:
notes:

Acceptance Sober Living Intake

Welcome to the Acceptance Sober Living intake wizard

Click next to begin!

General

Tell us about yourself

Contact Information

How can we reach you?

Contacts

Give us a few people that we can reach out to in case of an emergency. Include best phone number to contact.

Contact #1

Contact #1

Contact #1

Health/Medical Insurance

Enter your insurance provider(s) and policy numbers.

Insurance #1

Medical History

Tell us about your medical history.

Medical Tests #1

Medications

List the medications you are currently prescribed.

Medication #1

Treatment Centers

Tell us about any treatment centers you've previously been admitted into.

Treatment Center History #1

Client Referral Source

Occupancy

Sober Living History

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

Sober Living History #1

Employment

Tell us about your employment status. If you're currently unemployed select "unemployed" under "type"

Employment History #1

Living Arrangement

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

Living Arrangement History #1

Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"