Date:Date

Name: Client first nameClient last name

Date of Birth:Client birthdate

Current Address:Client AddressClient CityClient StateClient Zip

Phone:Client phone

Client marital status:Client marital status

Emergency Contact: Text field Relationship: Text field Phone number:Text field

Clean Date: Date

Do you have a source of income?Checkboxes

Monthly income amount:Text field

Current Treatment Center:Text field

Treatment Center Contact & phone number:Text fieldText field

Discharge Date:Date

History of inpatient treatment:

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Do you have any pending court dates? Checkboxes

Court Date:Date

Charges:

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Criminal history:Criminal History

Are you currently on parole or probation?Checkboxes

What are your reporting requirements?Text field

Are you required to register as a sex offender?Checkboxes

Do you have any physical or mental health issues? Checkboxes

If so, list diagnosis:Client diagnosis

Are you currently taking medication?Checkboxes

List all current medications, dose and treating physician:

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What is your drug of choice?Client substances of choice

What other substances have you used?Text field

How long have you been in active addiction?Text field

What do you hope to accomplish by living at the Dexter House?

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What is your longest period of recovery to date?Text field

What has been your biggest challenge in recovery?

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Please list the people, places and things that are unhealthy to your recovery:

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