Beauty For Ashes

Men's & Women Recovery

Address: 3228 MCCLELLAN BLVD ANNISTON, AL 36201

PHONE: (256)591-3329

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 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?

Street Address:

City:

State:

Zipcode:

Contacts

Give us a few people that we can reach out to in case of an emergency.

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

Insurance

Enter your insurance provider(s).

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 anything? 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

What allergies do you have? 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

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?

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:

Court

Have you ever been charged or convicted of a sex act? Yes / No

Do you have to register as a sex offender in any state? Yes / NO

If Yes, what state?

Date:

Signature: