Client First Name: Client first name
Client Last Name: Client last name
Date of Birth: Client birthdate
City: Client City
Zip: Client Zip
Phone: Client phone
Email: Client email
Insurance Information:
Insurances
Emergency Contacts:
Contact
List Custodial Children:
Family Members
Most Recent Treatment Center:
TreatmentCenterHistory
Substance of Choice:
Client substances of choice
Mental Health Diagnosis: Text field
Medications:
Initial here if you take NO medications: Initials Text field
Medication
Release of Information: I agree to allow The Fellowship and Fellowship Recovery to exchange my personal information between the staff of both organizations as it pertains to coordinating sober living placement and outpatient services. Initials Text field
Client Signature:
Signature
Date:
Date
Additional Notes:
Paragraph