Intake Form

Name Client first nameClient last name

DOB: Client birthdate
Substance of Choice: Client substances of choice
EmailClient emailPhoneClient phoneGenderClient gender
SSNSSN  Martial Status? Client marital status

Last Use: Text field
Desired Move In Date? Text field
Are you pregnant? Text field
Contacts: List Emergency Contact & Sponsor/Recovery CoachContact


Current Medications (If None you can Skip):Medication
Allergies:Client allergies
Health History (If None you can Skip):Client health problems
Mental Health History (If None you can Skip): Client diagnosis

Do You Have A Primary Care Provider? If so please list name and number Paragraph

Have You Previously Been in Recovery, if so for how long and when?RecoveryHistory

Are you on probation or parole? If so please list Probation Officers Name and Phone #: Text field

Are you experiencing Legal Problems? If Yes Please Describe: Text field

Do you have a car? If so do you have a drivers license and insurance? Text field

What do you think your best characteristics are? Paragraph
What list hobbies or special interests or talents: Paragraph

 

Who referred you? Text field

Any Other Questions? Paragraph


Signature: SignatureDate:Date