Fellowship IOP/Housing Application

Fellowship House Logo

Fellowship IOP / Housing Application

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