Client First Name: Client first name
Client Last Name: Client last name
Birthdate: Client birthdate
Today's Date: Date
Address: Client Address
City: Client City
State: Client State
Zip: Client Zip
Phone: Client phone
Email: Client email
Insurance Information:
Insurances
Emergency Contacts:
Contact
Additional Family Members:
Family Members
Sober Living History:
SoberLivingHistory
Treatment Center History:
TreatmentCenterHistory
Substance of Choice:
Client substances of choice
Medications:
Initial here if you take NO medications: Initials Text field
Medication
Kind of Meetings Attended:
Text field
Current Step:
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