Application Intake Form

Purpose:

This form is designed to gather essential information from individuals seeking assistance with substance abuse treatment and recovery resources. It helps us understand each individual’s unique needs, background, and health history to better provide personalized and effective support. Information collected will cover areas such as current health conditions, substance use history, personal and family medical history, mental health background, and any current treatment plans. This intake process is critical in developing an individualized care plan and connecting individuals with appropriate recovery services and resources.

Full Name*

First NameMiddle NameLast Name

Preferred Name

Preferred Pronoun

He/Him, They/Them, She/Her

Date of Birth*

Date

Social Security*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Please enter a valid phone number.

Sex assigned at birth:*

MaleFemale

Gender:*

MaleFemaleTrans Man (M to F)Trans Woman (F to M)

Race*

Hispanic Origin

CubanMexicanPuerto RicanOther Hispanic

Allergies

Emergency Contact Name*

Relationship to you*

Emergency Contact Phone Number*

How did you learn about this program

Employer

Employer Address

Employer Phone

How long have you been clean*

What was your drugs of choice*

Have you participated in a 12 Step program before?*

If SO where

Do you have a sponsor*

Resident Application Form

Applicant Information

Financial

Status

Medical Providers

Medical History

Consent Information