TLM - Intake Form

 

 

Transformational Living Ministries Intake Form


Welcome to the TLM intake wizard
Click next to begin!

General

Tell us about yourself

What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran status
How many Children do you have? Text field
Do you have a current DCS case? Dropdown
If Yes, DCS contact info: Text field

Contact Information

How can we reach you?

What is your email address?
Client email
At what phone number can we best reach you at?
Client phone
Street Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip

Contacts

Give us a few people that we can reach out to in case of an emergency.

Contact

Insurance

Enter your insurance provider(s).

Insurance

Medical History

Tell us about your medical history.

When was your last relapse date?
Recovery history 1 relapse date
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Have you been clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
What allergies do you have? No allergies? Move on to the next question.
Client allergies

Have you had any of the following tests?

Medical Tests
 

Medications

List the medications you are currently prescribed.

Medication

Treatment Centers

Tell us about any treatment centers you've previously been admitted into.

TreatmentCenterHistory

Client Referral Source

 

Who referred you to us?
Client Referred By

Occupancy

 

 
Are you incarcerated? Dropdown
If so Where? Text field
Are you currently in Treatment? Dropdown
If So Where? Text field
When will you be released? Date
 

Sober Living History

Tell us about any sober livings you've previously been admitted into.

SoberLivingHistory

Employment

Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"

EmploymentHistory

Living Arrangement

Tell us about your living arrangement prior to moving into this facility

LivingArrangementHistory
 

Legal History

Tell us about current and past Legal issues

Do you have any pending charges? Dropdown

If yes, what are they? Text field Text field

Any pending court dates? Dropdown  Dates? Date

Are you on Probation/Parol? Dropdown  IF yes, County? Text field  Officer? Text field

Do you have past felonies? Dropdown  If yes, tell us about them. Paragraph