General Information
Name Client first nameClient middle nameClient last name
Gender at birth Client gender
Current address Client Address
Date of Birth Client birthdate
Phone number Client phone
Email Client email
Recovery History
RecoveryHistory
Substance(s) of choice Client substances of choice
Do you attend recovery meetings? Checkboxes
TreatmentCenterHistory
If yes, where? Text field
List any diagnosis you have: Client diagnosis
List any medications you are currently on: Medication
Legal History
Probation
Do you have any convictions? Checkboxes
If yes, list types Text field
Do you have any pending charges? Checkboxes
If yes, list types Text field
Do you have any open CPS cases, or other types of cases? Checkboxes
Employment
Do you work? Checkboxes
If yes, where. Text field
Funding
What is your funding source for rent? Checkboxes