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Intake Form - Complete Form

Marital Status
Single
Married
Divorced
Employment Status
Currently Employed
On workers compensation
Disabled
Not currently employed
Do you have a car you will be bringing to the house?
Yes
No
Do you have a driver's license?
Yes
No
Is your car insured?
Yes
No
Do you currently have health insurance?
Yes
No
Currently in treatment?
Yes
No
Are you currently on probation or parole?
Yes - Probation
Yes - Parole
No - Neither
Have you been convicted of a violent crime?
Yes
No
Have you been convicted of a sex related crime?
Yes
No
Have you ever been convicted of Arson?
Yes
No
Have you ever experienced an Overdose?
Yes
No
Have you ever had a Heart Attack or Stroke?
Yes - Heart Attack
Yes - Stroke
Yes - Both
No - Neither

Recovery Questions

Have you been to AA or any 12 Step based fellowship?
Yes - Alcoholics Anonymous
Yes - Narcotics Anonymous
Yes - Opiates Anonymous
Yes - Other Fellowship
No - Never been
Are you willing to engage in 12 Step Meetings? Getting a sponsor, commitment, working the 12 steps and finding a home group.
Yes
No
Have you been in Sober Living?
Yes
No

Acknowledgements

Emergency Contact Relation to You
Family Member
Friend
Significant Other
Other
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