Are you completing this application for someone other than yourself? Radio buttons
If you answered yes to the preceding question, please answer the following:
Where is the applicant now? Dropdown
Tell us about the applicant
What is the applicant's first name?
Client first name
What is the applicant's middle name? No middle name? Move on to the next question.
Client middle name
What is the applicant's last name?
Client last name
When is the applicant's birthdate?
What is the applicant's race/ethnicity?
What is the applicant's gender?
What is the applicant's marital status?
Client marital status
Is the applicant a veteran?
Does the applicant have a current driver license or photo ID?
Does the applicant have a birth certificate?
Does the applicant have pending legal charges? Dropdown
What are the charges? Text field
Does the applicant have an attorney? Dropdown
Please list attorney's contact information?
Give us a few people that we can reach out to in case of an emergency.
Tell us about your medical history.
What is your sobriety date?
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Have you been clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
What allergies do you have? No allergies? Move on to the next question.
Have you had any of the following tests?