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.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Emergency Contact Relationship
Emergency Contact Address:
Ethnicity
Have you ever lived in sober living recovery housing before?
Describe your current situation and recovery goals
Marital Status