Steadfast Questionnaire
Once this questionnaire is submitted for review, you will then be contacted at the number you provide below to take next steps! If you have further questions or need immediate help, please call 407-747-9452.
Personal Information:
Full Name
First Name
Middle Name
Last Name
Age
Date of Birth
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Month
-
Day
Year
Sex
Please Select
Male
Female
Height
Weight
Phone Number
E-mail (Optional)
Are you currently in treatment?
Yes
No
If yes, what facility are you in?
If in treatment, please provide counselor's name
Counselor's Phone Number
Extension
How did you hear about us?
Questions and Details:
Why are you seeking sober living with Steadfast Recovery?
What is your clean date? (CLEAN DATE IS THE FIRST DAY COMPLETELY ABSTINENT FROM ALL MIND AND MOOD ALTERING SUBSTANCES- this includes alcohol, THC, Kratom and any other prescribed narcotic or controlled substance, even if not being abused.)
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Month
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Day
Year
Date
List all substances you were using.
Do you have any mental health diagnosis? If yes, please list.
List all prescribed medications you are currently taking or plan to take while at Steadfast. (All medications are examined prior to intake and will need to be approved)
Do you have any current legal issues? If so, what are they and what obligations do they require of you? (Probation, drug court, etc.)
Do you have any past felonies? If so, what are they and when did they occur?
In what county did your legal issues take place?
How many times have you been to treatment (alcohol/drug rehab) in the last 2 years?
*
How many times have you been baker acted or in any psychiatric unit in the last 3 years?
*
What date are you looking to move into Steadfast Recovery?
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Month
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Day
Year
Date
Submit
Should be Empty: