First Name: Client first name  Last Name: Client last name 

Nickname: Client nickname

Birthdate: Client birthdate   

Gender: Client gender   

SSN: SSN   

Veteran Status: Client veteran status

Marital Status: Client marital status   

Race: Client race   Pronoun: Client pronoun

Phone Number: Client phone        Email Address: Client email

Address: Client Address     City: Client City    State: Client State   

Zipcode: Client Zip

Client Referred By: Text field

Anticipated Date of Entry:  Date   

Please include Emergency Contact:   Contact 

 

Client substances of choice

TreatmentCenterHistory

SoberLivingHistory

 Recovery Date: Date

Therapist/Clinician

Client Health Concerns: Client health problems

Client Diagnosis: Client diagnosis

Medication      

Client allergies

Have you ever been arrested for any sexual or violent crimes? If so, what charges?

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Have you ever been incarcerated? If so where, and how long? What charges?

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Are you on probation? If so, who is your probation officer? What are your terms of probation?

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How do you plan on paying for your stay? We accept cash, personal checks, money orders, and also take MDRN funding. We currently do not accept private insurance.

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Client Discharge Date from Referral Source: Client discharge date   

What would you like to accomplish during your stay with Awaken Recovery? Paragraph

What potential challenges do you see on your road to recovery?

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My signature below means I have read and understand the Awaken Recovery Foundation (ARF) Guidelines and Policies.

I understand that my residency with ARF is transitional. I also understand that upon acceptance and entrance into the house, I waive all legal rights as a tenant.

I furhter acknowledge and accept that Maryland Landlord/Tenant Laws do not apply to my residency at ARF and that I can be discharged from the premises immediately without due process of the law, should it be determined by Management to be in the best interest of the house and/or other house members.

Should I refuse to leave the premises immediately upon discharge, I may be charged with criminal treaspass and the local Police Department will be called to escort me off the property.

*By signing, I agree that I have read the house rules, rights, and responsibilities; understand them completely, and will follow them.*

By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.

 Type Full Name: Text field

Client Signature: Signature       

Signature Date:  Date