This form is for potential clients that are currently admitted to inpatient treatment. Please complete ALL fields with an asterisk (*) before submitting.
*Who referred you to Wings of Freedom?
*Reason for applying? Paragraph
*What is your expected move-in date? Date
Full name? Client first name Client middle nameClient last name
*Birthdate? Client birthdateText field Gender Client gender Race/ethnicity? Client race
*Clients Social Security Number: SSN
*Marital status? Client marital status Spouse Text field
Maiden name? Text field
*Are you enrolled in a tribe? Dropdown
Are you a veteran? Client veteran status
*Cell phone number? Client phone Email address? Client email
*What is a good mailing address?
Client Address Client City Client State Client Zip
*Do you have 30 days of sobriety? Dropdown
*Can you pass a drug and/or an alcohol test? Dropdown
*What is your substance(s) of choice? Client substances of choice
*Have you been clinically diagnosed with anything? Client diagnosis
*Do you have any health problems? Client health problems
Additional medical notes.
Client medical notes
*Are you on any medications? Dropdown
*List ALL the medications you are currently prescribed.
Additional medication notes.
Have you ever been convicted of a felony? Dropdown
*Have you ever been arrested for a "sex crime"? Dropdown
Do you now, or have you ever had any "gang affiliation"? Dropdown
*DOC Number: Text field
*Are you currently on probation/parole or drug court? Dropdown
*Source of Income: Dropdown
*What is your workers contact information? Text field Text field Text field
*Have you ever lived in another sober living program? Dropdown
*Do you have any minor children? Dropdown
*Do you plan on your children living with you? Dropdown
*Do you have an open DHS case? Dropdown
*What are your beliefs? Dropdown
Please do NOT leave any unanswered questions. If incarcerated, please attach a copy of your CRC card (consolidated record card).
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.