Intake | A New Dawn

Intake Form

First name

Last name

Please provide an emergency contact name (relation to you) and phone number.

1) Do you have a sponsor? 2) Do you have a therapist/clinician? 3) Do you have a probation/parole officer? If yes to any of the above, please provide their name, role, contact information, and any other relevant details.

When is your sobriety date?

Month

Day

Year

Medical History: Please provide us with any medical concerns, mental health diagnoses, and any medications you are prescribed.

Do you smoke?

Yes

Employment: Please tell us where you are employed (or where you have applied to) and your start date.

Communal Living: Can you walk independently, participate in household chores, dress yourself, bath regularly, and maintain bladder/bowel control?

List ANYTHING else we should be concerned about or any concerns you may have.