TLM - Intake Form



Transformational Living Ministries Intake Form

Welcome to the TLM intake wizard
Click next to begin!


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
Client City
Client State
Client Zip


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



Enter your insurance provider(s).


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


List the medications you are currently prescribed.


Treatment Centers

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


Client Referral Source


Who referred you to us?
Client Referred By



Are you incarcerated? Dropdown
If so Where? Text field
Tentive release date?  Date
Are you currently in Treatment? Dropdown
If So Where? Text field
When will you be released? Date
Will you have your $300 entrance fee?Dropdown

Sober Living History

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



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


Living Arrangement

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


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