Fellowship IOP/Housing Application

Fellowship IOP / Housing Application

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:

Text field

 

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