Name Client first nameClient last name
DOB: Client birthdateSubstance of Choice: Client substances of choiceEmailClient emailPhoneClient phoneGenderClient genderSSNSSN Martial Status? Client marital status
Last Use: Text fieldDesired Move In Date? Text fieldAre you pregnant? Text fieldContacts: List Emergency Contact & Sponsor/Recovery CoachContactCurrent Medications (If None you can Skip):MedicationAllergies:Client allergiesHealth History (If None you can Skip):Client health problemsMental Health History (If None you can Skip): Client diagnosisDo 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 fieldAre you experiencing Legal Problems? If Yes Please Describe: Text fieldDo you have a car? If so do you have a drivers license and insurance? Text field
What do you think your best characteristics are? ParagraphWhat list hobbies or special interests or talents: Paragraph
Who referred you? Text fieldAny Other Questions? ParagraphSignature: SignatureDate:Date