A-CURE Basic Application

1
Basic Information
2
Full Name* This field is required.
First Name
Last Name
3
Todays Date* This field is required.
Date
Month
Day
Year
4
Intended Occupancy Date* This field is required.
Date
Month
Day
Year
5
What Type Of Bed Are You Seeking?* This field is required.
Please Select
Please Select
Self Pay
Basic Needs
Not Sure
Other
6
Sobriety Date* This field is required.
Date
Month
Day
Year
7
Phone Number* This field is required.
Please enter a valid phone number.
8
Email
example@example.com
9
Current Address* This field is required.
10
Referral Source
11
Referral Source Contact Number* This field is required.
Please enter a valid phone number.
12
SS #* This field is required.
13
Date of Birth* This field is required.
Date
Month
Day
Year
14
How Do You Identify?
Female
Male
Other
15
Medicaid Client ID #* This field is required.
16
Emergency Contact Name* This field is required.
17
Emergency Contact Number* This field is required.
Please enter a valid phone number.
18
Legal History
19
Have You Ever Been Arrested?* This field is required.
Please Select
Please Select
YES
NO
20
**If Yes, Please explain
21
Parole/Probation Officers Name
22
Parole/Probation Officers Phone
23
Drug & Alcohol History
24
Explain any history of drug or alcohol abuse: (how used/ how much / age of use)* This field is required.
25
Psychiatric & Medical History

Please list current prescribed medications & diagnosis.
26
Medication, Dosage & Diagnosis* This field is required.
27
Income Information
28
Current Employer
29
Employer Phone Number
30
If not employed List Source of Income
31
Monthly Income* This field is required.
32
Are You Currently At Your In Person A-CURE Intake?* This field is required.
No
Yes
Should be Empty:

Basic Information

Legal History

Drug & Alcohol History

Psychiatric & Medical History

Income Information