Intake Form

First Name *

Last Name *

Email *

When is your birthdate? *

What is your middle name? (No middle name? Move on to the next question.)

Nick Name

What is your marital status? *

Spouse Partner Name

Spouse Partner Phone

Emergency Contact - Name *

Emergency Contact - Phone Number *

Emergency Contact - Email *

Emergency Contact - Relationship Type *

Emergency Contact - Additional Notes

What is your primary race/ethnicity?

Are you a veteran? *

ID/CDL# *

Military ID #

Monthly Income 1 *

Monthly Income Source 1 *

Monthly Income 2

Monthly Income Source 2

Other Monthly Income

Available Savings *

Expenses *

Do you have any regular medical appointments? Please explain. *

Do you have any dietary restrictions? *

Treatment Center History 1 — name: *

TreatmentCenterHistory 1 — address: *

TreatmentCenterHistory 1 — city: *

TreatmentCenterHistory 1 — state: *

TreatmentCenterHistory 1 — zip: *

TreatmentCenterHistory 1 — type:

TreatmentCenterHistory 1 — started:

TreatmentCenterHistory 1 — ended: *

TreatmentCenterHistory 1 — notes: *

TreatmentCenterHistory 1 — Primary reason for discharge:

SoberLivingHistory 1 — name: *

SoberLivingHistory 1 — description: *

SoberLivingHistory 1 — address: *

SoberLivingHistory 1 — city: *

SoberLivingHistory 1 — zip code: *

SoberLivingHistory 1 — admitted: *

SoberLivingHistory 1 — discharged: *

SoberLivingHistory 1 — estimated length of stay:

SoberLivingHistory 1 — primary reason for discharge:

Do you have any health problems? *

Client insurance provider: *

Client insurance plan: *

Client insurance group ID: *

Client insurance policy #: *

Client insurance Contact # *

Client insurance other: *

Do you smoke? *

List food items that you do not like:

List your favorite foods:

List Activities you enjoy doing:

Do you work or volunteer anywhere?

Are you currently experiencing any of the symptoms listed? *

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