Intake Form

 

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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?
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 social security number?
SSN
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
 

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
What is your current drivers license number?
Text field
*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:
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. Include best phone number to contact.
Contact One Contact
Relation to client Text field
 
Contact Two Contact
Relation to client Text field
 
Contact Three Contact
Relation to client Text field

Health/Medical Insurance

Enter your insurance provider(s) and policy numbers.
Insurance

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 choiceClient substances of choiceClient substances of choice
Have you been clinically diagnosed with any mental health conditions? 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
Do you have any allergies? No allergies? Move on to the next question.
Client allergies

Have you had any of the following tests?

Medical Tests
 

Medications

List the medications you are currently prescribed.
Medication

Treatment Centers

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

Client Referral Source

 
How did you hear about Acceptance Sober Living?
Text field
If you were referred, who referred you to us?
Client Referred By

Occupancy

 
What facility will you be staying at?
Client facility
What date will the you be admitted on?
Client admit date
What is the estimated length of stay?
Client estimated length of stay
*Acceptance Sober Living requires a minimum commitment of six months.
When will the you be discharged?
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"
EmploymentHistory

Living Arrangement

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