Preliminary Questions
The Well cannot accept La Frontera clients. Please list the name of your behavioral health agency.
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The Well is a Christ-centered faith-based recovery home. There is a Bible Study in the house on Saturdays from 12-1 pm. Guest at The Well are required to attend. Are you willing and able to attend?
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General
First name
Client first name
Last name
Client last name
Date of Birth
Client birthdate
Email address
Client email
Phone number
Client phone
Gender
Client gender
Marital status
Client marital statusAre you working towards reunification with your child/children?
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Religious preference?
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List two emergency contacts
Contact
Substance Abuse History
What were the last substances that you used and when?
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What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Do you engage in medical assisted treatment services?
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Are you currently in a treatment program?
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Name of treatment facility
TreatmentCenterHistory
Medical History
Do you have any mental health diagnosis? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any medical diagnosis? Add multiple by clicking in the box and selecting different options
Client health problems
Medication
Are you at risk for exposure to any communicable diseases, or have you been in contact with someone who has?
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Are you experiencing shortness of breath, coughing, fever, or other symptoms of Coronavirus and/or a flu?
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Have you tested positive for COVID-19 in the past 10-days?
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Are you currently awaiting results from a COVID-19 test?
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The monthly fee is $700.
Income and Employment
Do you currently have an income?
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Are you able to work?
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Do you have any barriers to gaining employment?
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Are you currently employed?
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What is your current occupation?
EmploymentHistory
Admissions
When would you like to move?
Date
What is the estimated length of stay?
Client estimated length of stay