Zera House Intake Form
Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What does safety mean to you?
What is your current living situation?
Do you have a medical history or any health conditions?
Have you had any mental health diagnoses?
Are you currently taking any medication? If so, which medication?
Are you on Medically Assisted Treatment?
Yes
No
What kind of MAT if you answered yes to the previous question?
What is your sobriety date?
-
Month
-
Day
Year
Date
Do you attend any meetings?
Do you have a sponsor?
What is your view on God and religion?
Where do you see yourself five years from now?
Is there anything else you wish to share with us?
Submit
Should be Empty: