Online Intake Form

Prospective Resident's Contact Information

Name:*

Telephone:*

Email Address:*

Street Address:*

City:*

State:*

Zip Code:*

Emergency Contact

Contact Name:*

Contact Telephone:*

Contact Relationship:*

Drug/Alcohol & Treatment History

Substances Abused:*
HeroinCrackOxycontinAlcoholMarijuanaPercosetPillsMethCocaineKetamineEcstasyOtherNot Sure

Sobriety Date:*

Previous Treatment Centers:*

Previous Sober Living Facilities:*

Legal Information & History

On Parole?*

On Probation?*

Charges Pending?*

Registered Sex Offender?*

If yes to any above, please describe:

Medical History

Have Medical Insurance?*

Insurance Provider:

Previous Suicide Attempt:*

Prescription Medications:

Doctor's Name:

Doctor's Telephone:

List Allergies and Conditions:

Employment Information

Currently Employed?*

Able to Work?*

Employer's Name:

Supervisor's Name:

Shift Start Time:

Shift End Time: