The Well Women's Serenity Application

The Well Women's Serenity House Application


Welcome to the Sober Homes intake wizard
Click next to begin!

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 status
Are 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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Fees

The monthly fee is $700.

How will you pay your fees? 

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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

  

 

Client Referral Source

Who referred you to us?
Client Referred By

 

 

Admissions

When would you like to move?
Date
What is the estimated length of stay?
Client estimated length of stay