Saltwater Mission Intake Form

Saltwater Mission Intake Form

Intake Eligibility Checklist
Thank you for your interest in Saltwater Mission and for your courage in seeking help. This intake form is the first step in determining eligibility for our outpatient recovery and discipleship program and helps us discern how we may best walk alongside you in this season.The information you share allows our team to review readiness, understand your needs, and communicate expectations clearly. Once the intake form is reviewed, we will connect with you personally to discuss next steps and answer any questions you may have.
Personal Information

Please fill out the intake form in full, ensuring that all information is accurate and complete. Your responses will be used to assess your eligibility for admission into our program.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Marital Status
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address
CityProvincePostal Code
Please list any medical issues you currently have AND any medications you are currently taking.
Check any mental health issues that you have been diagnosed with by a clinical professional.
Have you been hospitalized in the past year?

Other
What substances are you using currently and how often?
How long have you been struggling with addiction?
Have you previously attended any recovery or treatment programs?
Please describe any previous recovery or treatment experiences.
Are you a registered sex offender?

Other
Have you ever been convicted of a sex crime?

Other
Are you currently involved in any legal matters, including pending charges, court dates, probation, or parole? If yes, please provide details.
Do you owe and/or pay child support payments?

Other
Please describe your previous work experience, including where you worked and how long you were employed
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What are your main goals for recovery?
Do you have any special skills or abilities? If yes, please describe
Should be Empty:

Saltwater Mission Intake Form

Personal Information