Step 1) Application: Form B - Inpatient Treatment

Client Application

This form is for potential clients that are currently admitted to inpatient treatment. Please complete ALL fields with an asterisk (*) before submitting.


Client Referral Source

 
*Who referred you to Wings of Freedom?

Text field

*Reason for applying? Paragraph

*What is your expected move-in date? Date

General

 

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

 

Contact Information

*Cell phone number? Client phone Email address? Client email

*What is a good mailing address? 

Client Address Client City Client State Client Zip

 

Medical History

 *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

 

Medications


 *Are you on any medications? Dropdown

*List ALL the medications you are currently prescribed.

 

*Medication

Additional medication notes.

Client medical notes


Criminal Background

We require all clients to have a background check before entering our program. Felonies will NOT disqualify clients application.

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


Employment

*Source of Income: Dropdown


Living Arrangement

*TreatmentCenterHistory

*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

Child's Name Date of Birth Gender Current Household
Text field Date Dropdown Dropdown
Text field Date Dropdown Dropdown
Text field Date Dropdown Dropdown
Text field Date Dropdown Dropdown
Text field Date Dropdown Dropdown
Text field Date Dropdown Dropdown

 

Spiritual Status

We are a faith-based sober living program. Let us know about your faith. This does NOT decline any potential clients from being accepted into the program if they have different beliefs. 

*What are your beliefs? Dropdown


Submission

Please do NOT leave any unanswered questions. If incarcerated, please attach a copy of your CRC card (consolidated record card).

 

Signature: Signature

Date: Date

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.