Online Application Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
Insurance Type
*
Applicants Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Phone Number
*
Please enter a valid phone number.
Current Email
example@example.com
Professional’s name that is making this referral behalf of the client
*
First Name
Last Name
Professional’s place of employment
*
Professional’s email
*
example@example.com
Professional’s phone number
*
Please enter a valid phone number.
Number of days sober
*
Minimum of 30 days required prior to admission date
Do you have difficulty living with multiple people?
*
Yes
No
If you have difficulty living with others, please explain
*
Date the applicant intends to enter our housing facility
*
Emergency Contact's name
*
Emergency Contact's phone number
*
Please enter a valid phone number.
Emergency Contact's Relationship to applicant
*
Please identify and list two goals that you would like to achieve in the next 6 months
*
Mental and/or Chemical Health Diagnosis
*
Are you able to independently manage your medications?
*
Yes
No
Current medication(s) & dosage(s)
*
Do you have any felony convictions?
*
Yes
No
Please list any felony convictions
*
Must include pending charges as well.
Are you currently on probation or parole?
*
Yes
No
If you are on probation or parole, please explain
*
Probation and/or Parole Officer's name & County
*
Probation and/or Parole Officer's phone number Phone Number
*
Please enter a valid phone number.
Do you currently have a Case Manager?
*
Yes
No
Case Manager's Name
*
Case Manager's County
*
Case Manager's phone number
*
Please enter a valid phone number.
Do you currently have a Financial Worker?
*
Yes
No
Financial Worker's Name
*
Financial Worker's County
*
Financial Worker's phone number
*
Please enter a valid phone number.
Do you currently receive any sources of income? Ie: SSI, RSDI, Unemployment, Child Support, etc.
*
Yes
No
If you currently receive a source of income, what type(s)?
*
Are you currently enrolled or plan to be enrolled in Drug Court?
*
Yes
No
If you are enrolled or plan to be enrolled in Drug Court, please provide specific information
*
Drug Court Probation Officer's name, phone number, county, & phase.
Allergies
*
Primary Care Provider
*
Primary Care Location
Primary Care Location
*
Primary Care Phone Number
*
Please enter a valid phone number.
Psychiatrist
*
Psychiatry location
*
Psychiatry provider's phone number
*
Please enter a valid phone number.
Are you currently enrolled or plan to be enrolled in Intensive Outpatient Programming?
*
IOP location & provider's name & phone number
*
Any other notes
DA
*
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