Midway Recovery Systems
Resident Intake Application
Confidential 

Personal Information
Full Name:Client first nameClient last name 
Date of Birth: Client birthdate Age: Text field
Phone Number:Client phone
Email Address: Client email
Current Address: Client AddressClient CityClient StateClient Zip

What county are you from? Text field

Race:Client race

Sexual Orientation Radio buttons

Marital Status:Client marital status

Are you a Veteran?Client veteran status

Who is completing this application? Text field

Reason for Seeking Treatment

Please briefly explain why you are seeking treatment and a recovery-based living environment at this time:

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Are you willing to participate in house meetings, groups, chores, and abide by the program guidelines? Radio buttons

 

Dependents:Dropdown

What are their ages and who has custody?Paragraph

Current Custody Issues or DFCAS involvement? Dropdown

Please explain: Paragraph

Education

What is the highest level of education completed? Text field
Are you currently enrolled in any school, training, or educational program?
Dropdown
If yes, please explain:Text field

Referral Source:Client Referred By
How did you hear about us?:Text field

Background Information

Legal 

Is the applicant currently incarcerated?
Dropdown

If yes:

County of incarceration: Text field
Facility name:Text field
Reason for incarceration:Paragraph

Anticipated release date (if known):Date

Probation

Probation

Pending Case(s), probation or parole:Dropdown

If yes, please expain:Paragraph

Is there an opportunity to participate in a face-to-face intake interview?Dropdown

 Access Zoom or phone for a remote interview?  Dropdown

Do you have a court mandate to treatment? Dropdown

If yes, please explain: Paragraph

Substance Use History

Client substances of choice

Last Date of Use? Date

Age of First Use:Text field
Are you currently on any form of Medication-Assisted Treatment (MAT)?Dropdown

If yes, list medication:Text field

Medical and Mental Health History

Do you have any medical conditions? Dropdown

If yes, please list:       Client health problems

Do you take prescribed medications? 

List all current medications for Medical treatment: Medication

Have you ever been diagnosed with a mental health condition?Dropdown
If yes, : Client diagnosis

Hospitalizations, Suicidial Ideation and/or unsuccessful Attempt (if yes to any please explain)Dropdown

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List all current medications for Mental Health treatment:Medication

If accepted will you have a 30 day Supply? Dropdown

 

If no, explainParagraph

Have you recently had any of the following tests?

Checkboxes

 

Do you have any Allergies? Dropdown     Text field

 

Previous Treatment/Recovery History

Have you lived in a sober living home before?Dropdown

If yes, when and where? Paragraph

Identifying Documents

Please check all that the applicant currently possesses:

Checkboxes

Other:Text field

If no documents are available, is the applicant willing to work on obtaining them? Dropdown
Please provide additional information is applicable Paragraph

 

Recovery Support
Do you have a sponsor or plan to get one?  Dropdown

Do you currently attend any recovery meetings?  Dropdown

Prefered Pathway to Recovery (type of meetings i.e. AA/NA/CR)? Paragraph

Employment and Finances

Are you currently employed?Dropdown

If yes, where? Text field
Work schedule: Text field

Do you have the ability to pay program fees?Dropdown

Please Provide additional informationParagraph

 

 

 

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