Metaverse Confidential Application

Metaverse Confidential Application

Thank you for choosing the Metaverse Recovery Program for your journey towards healing and recovery. Please take a few moments to complete this intake application. Your responses will help us tailor our services to best meet your needs.
Legal Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
SS#
Confidentiality Preference
Do you wish to keep your identity concealed during counseling and therapy sessions?

YesNo
Avatar Information (if keeping identity concealed)
Avatar Name:
Preferred Avatar Appearance: [Brief Description]
Phone/Cell*
Please enter a valid phone number.
Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Do you have a sponsor?

YesNo
Name
Will it be okay for us to contact them?

YesNo
Phone Number
Please enter a valid phone number.
Are you on Probation/Parole?

YesNo
Please list your P.O.'s name
Do we have your permission to contact him/her?

YesNo
Please list your P.O.'s phone number.
Please enter a valid phone number.
Do you have a job?

YesNo
Are you struggling with a drug or alcohol addiction?

YesNo
Do you need drug or alcohol counseling?

YesNo
How long have you been fighting this addiction?
Why do you think you haven’t overcome this addiction?
Do you have any physical disabilities?

YesNo
Please explain
Do you or anyone in your family have a mental disorder?

YesNo
Please list relationship or self
Are you presently on medication?

YesNo
What type of meds and for what purpose?
What gender do you identify with?
Who should we contact in case of an emergency?
Name
Phone Number
Please enter a valid phone number.
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Do you want to add more contact(s)?

YesNo
Name
Phone Number
Please enter a valid phone number.
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Do you want to add more contact(s)?

YesNo
Name
Phone Number
Please enter a valid phone number.
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Do you have a computer with a camera?

YesNo
Are you involved with another program/agency?

YesNo
Please name the program and how they are helping you.
Please list 3 reasons we should accept you in this program:
INITIAL HERE: The information to be disclosed is confidential and is provided only to I’m In Transition. I understand that I may revoke this consent at any time by notifying the Provider*
INITIAL HERE: I consent that the requested information is true to the best of my ability. I understand that I can be revoked from the program if information is falsified.*
Should be Empty:

Metaverse Confidential Application

Confidentiality Preference

Avatar Information (if keeping identity concealed)