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

Race:Client race

Marital Status:Client marital status

Are you a Veteran:Client veteran status

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

Who is completing this application?

Applicant, Someone on behalf of the applicant: Dropdown

If someone else is completing:

Paragraph

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

Paragraph

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

Reason for Seeking Treatment

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

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

Paragraph