Contact Information

What is your email address?

At what phone number can we best reach you at?

Street Address:

City:

State:

Zipcode:

Marital Status:
SingleMarriedDivorcedWidowed

Do you have children?
YesNo

BackNext

Emergency Contacts

Contact #1

Name:

Phone:

Email:

Notes:

BackNext

Treatment & Medical History

When was your first use date?

What is your substance(s) of choice?

Add multiple by clicking in the box and selecting different options

Substances of choice
Prescription OpioidsMethAlcoholDepressantsStimulantsMarijuana

Have you been clinically diagnosed with anything?

Add multiple by clicking in the box and selecting different options

Diagnosis
Mental DisorderBipolar DisorderAnxiety DisorderSchizophreniaAnxietyPosttraumatic Stress Disorder (PTSD)

Do you have any health problems?

Add multiple by clicking in the box and selecting different options

Health Problems
Heart troubleHigh blood pressureArthritis or RheumatismCancerEmphysema or chronic bronchitisDiabetes

What kind of meetings do you attend?

Add multiple by clicking in the box and selecting different options

Substances of choice
Refuge RecoverySmart RecoveryAANASLAA

Tell us about any treatment centers you've previously been admitted to:

Treatment Center History #1

Name:

Address:

City:

State:

Zip:

Started:

Ended:

Notes:

Type:
Treatment center typeIOPOPResidentialDetox

Reason for Discharge:
Treatment center reason for dischargeFinancialAt Staff RequestRelapsedNormal Transition

List the medications you are currently prescribed:

Medication #1

Name:

Dosage:

Quantity:

Category:
AMMiddayEveningPMPRN

Frequency:

Md:

Notes:

Pill count:

Discontinued at:

Enter your insurance provider:

Insurances #1

Name:

Policy number:

Group:

Plan:

Phone number:

Other:

What is your current mental wellness practice? (meditation, breathwork, reading, etc). Please provide a complete and thorough answer.

What is your current physical wellness practice? (yoga, running, weightlifting, etc). Please provide a complete and thorough answer.

BackNext

Legal History

Are you currently on probation?

Probation #1

Probation Start Date:

Probation End Date:

Notes:

Do you have a criminal history?

Criminal History #1

Are you currently involved with the Criminal Justice System?
YesNo

BackNext

Legal History

Are you currently on probation?

Choose referrer...(Valiant): Valiant(Denver Women's Recovery): Denver Women's Recovery(Alumni Referral): Alumni Referral

BackNext

Occupancy & Sober Life History

When are you looking to be admitted?

What is the estimated length of stay?

Tell us about any sober livings you've previously been admitted into:

Sober Life History #1

Name:

Description:

Address:

City:

State:

Zip Code:

Admitted:

Discharged:

Estimated Length Of Stay:

Reason for Discharge:
Sober life reason for dischargeFinancialAt Staff RequestRelapsedNormal TransitionSober life reason for discharge

Tell us about any sober livings you've previously been admitted into:

Client Notes #1

Notes:

BackNext

Employment

Tell us about your employment status:

Employment History #1

Employer Name:

Employment Position:

Employment Income:
No income<$000$15000 - $30000$30000 - $50000>$50000

Employment Started:

Employment Ended:

Employment Type:
Full-timePart-timeUnemployedNot in Labor ForceHomemaker

Employment Notes:

How do you plan on meeting the monetary requirements of living in sober living?

Client Notes #1

Notes:

BackNext

Other

Is there anything else you'd like us to know?

Client Notes #1

Notes:

Back