Demographics:

First Name: Client first name

Middle Name: Client middle name

Last Name: Client last name

DOB: Client birthdate

Address: Client Address

City: Client City

State: Client State

Zip Code: Client Zip

SSN: SSN

Race: Client race

Marital Status: Client marital status

History

Insurance: Insurances

Have you ever been diagnosed with with: Client diagnosis

Do you have any physical limitations or health problems? Client health problems

List any medications you take prescribed or not prescribed? (include vitamins, herbs, etc): Medication

Have you ever been to treatment before? Which facility? When? Paragraph

Have you ever been to a sober living before? Which facility? When? Paragraph

What is your highest level of education? Paragraph

 

Employment

Are you currently employed? EmploymentHistory

Are you willing to accept any type of employment? Checkboxes Checkboxes

Criminal Justice Involvement

Please explain your history. Criminal History

Who is your attorney? Text field Number? Number field Email? Text field

Are you (or will you  be) on probation? Checkboxes Checkboxes

 Who is your probation officer? Text field

 Probation Probation Number? Number field 

Probation officier Email? Text field

Are you (or will you be) on parole? Checkboxes Checkboxes

Who is your parole officer? Text field Number? Number field Email? Text field

Questionnaire

Are you dependent on an substance? Checkboxes Checkboxes

What is your substance(s) of choice? Client substances of choice

If you have mental illness, are you willing to commit to therapy and comply with the treatment plan they put in place? Checkboxes Checkboxes

Do you see a therapist? Therapist/Clinician

Do you have children? Checkboxes Checkboxes How many? Number field How old are they? Number field Can you have contact? Checkboxes Checkboxes

Do you have an open DCS case? Checkboxes Checkboxes If so, what county? Text field Who is your case worker? Text field Case worker number? Number field

Are you willing to be without a cell phone for 90 days? Checkboxes Checkboxes

Are you willing to be without a car for 30 days? Checkboxes Checkboxes

Are you willing to have no male contact for at least 30 days? Checkboxes Checkboxes

What tools are you looking for in a residential program? Paragraph

Are you willing to go to any length to recover from drugs and alcohol? Checkboxes Checkboxes

Are you willing to commit to a 6 to 9 month program? Checkboxes Checkboxes

Are you willing to stop communicating with others that use, or that are currently incarcerated? (Even family members) Checkboxes Checkboxes

Please explain what your addiction looks like in your life. Please include any case numbers, counties, and dates.

Paragraph

Emergency Contact

Person to notify in case of emergency: Family Members

Phone number: Text field

Checkboxes Checkboxes I have voluntarily provided the above contact information and authorize Ruth House and its representatives to contact any of the above on my behalf in the event of an emergency. 

Signature

Signature

Date

Date

 

*Please remember, the more you check in, the more willingness to change it shows and to ensure placement and position on the waitlist.*