General
Are you completing this application for someone other than yourself? Radio buttons
If you answered yes to the preceding question, please answer the following:
Contact
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?
Client birthdate
What is the applicant's race/ethnicity?
Client race
What is the applicant's gender?
Client gender
What is the applicant's marital status?
Client marital status
Is the applicant a veteran?
Client veteran
Does the applicant have a current driver license or photo ID?
Radio buttons
Does the applicant have a birth certificate?
Radio buttons
Legal Information
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?
Contact
Contacts
Give us a few people that we can reach out to in case of an emergency.
Contact
Medical History
Tell us about your medical history.
What is your sobriety date?
RecoveryHistory
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
Client diagnosis
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.
Client allergies
Have you had any of the following tests?
Medical Tests