General
Tell us about yourself.
What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran status
Number of Dependents
Text field
Highest Grade Completed
Text field
Have you ever been clinically diagnosed with a Mental Health Disorder? Add multiple by clicking in the box and selecting different options
Client diagnosis
Hospitalizations, Suicidial Ideation and/or unsuccessful Attempt (if yes to any please explain)
Client notes
Substance Use History
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
When was your last use? Add multiple by clicking in the box and selecting different options
Client notes
Medical History
Tell us about your medical history.
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
Do you have any Allergies? No allergies? Move on to the next question.
Client allergies
Have you had any of the following tests?
Medical Tests
Treatment Centers
Tell us about any treatment centers you've previously been admitted into.
Client notes
Sober Living History
Tell us about any sober livings you've previously been admitted into.
Client notes
Client notes
Resident Referral Source
How did you hear about us?
Client Referred By