Client Intake Form

Client Intake Form

Please fill out this form to help us understand your needs and facilitate your admission process.
Full Name*

First NameMiddle NameLast Name
Alias
May include nicknames,etc.
Sober Date
date of sobriety being drug and alcohol free
Date Of Birth
SSN
Contact Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Name of Insurance & Policy Number:
Health Insurance Effective Date:*

MonthDayYear
effective date of coverage
Current Address:

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.
Emergency Contact Relationship
Emergency Contact Address:
Ethnicity

Hispanic/LatinoAmerican Indian/Alaskan NativeAsianBlack/ African AmericanNative Hawaiian/ Pacific IslanderWhiteDon't KnowRefused to Answer
Have you ever lived in sober living recovery housing before?*

YesNo
Describe your current situation and recovery goals
Marital Status

SingleNever MarriedDivorcedMarried & Living w/ SpouseMarried & Not Living w/SpouseCommon LawLiving TogetherWidowedOtherRefused