application_crm | elranchodelavida

Your Name *

Preferred Name *

Date of Birth *

Email *

Phone *

Where are you currently living? *

Are you discharging from a substance abuse facility? *

Expected discharge date

Expected move-in date

Will you be attending an intensive outpatient program (IOP)?

Will you be bringing a vehicle? *

Where do you plan on living after staying with us? Have you lived there before?

Are you currently employed now? Do you plan to remain employed here during your stay with us? *

How will you occupy your time while staying with us?

Working job(s) 40 hours per week or more

Working job(s) 20-40 hours per week

Working job(s) less than 20 hours per week

In school part or full time

Community service and volunteering

None of the above

Please describe your current sobriety status *

Substance use history. Please tell us what drugs you use or have used, how long you have used drugs, how much, and how frequently you use. *

Are you currently taking any medication to help with your addiction? (such as Suboxone, Vivitrol) If so, please tell us which.

Medical Diagnosis and Mental Health Diagnosis. Do you have any medical conditions or disabilities? List all your mental health diagnoses and conditions. *

Please list any and all medications you are taking. Please include dosages if you can. *

Legal history. Please describe any legal issues you may have experienced. Please include arrests, convictions, etc.

Are you currently or have you ever been incarcerated? *

Are you currently under community supervision or supervised release/ Parole? If so, please describe the conditions of your supervision. May we contact your PO? *

Emergency contact name *

Emergency contact phone number *

Emergency contact email address *

Emergency contact relationship *

Do you currently have MaineCare? *

Yes

No

Do you have other insurance? *

Yes

No

By entering your FULL NAME here you certify that all of the information provided is accurate and true. If you are submitting for a client, please sign YOUR name and indicate as such. *

Company Name

How did you hear about us? *

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