Intake Application for Substance Abuse Program | Sonrise Teen & Adult Challenge

Home
The Program
- Application
GSNL Enhancements
- Lessons from The Land
- Word on the street
Festival of the Wichitas
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Contact

Reach Out

(580) 429-3940

Home
The Program
- Application
GSNL Enhancements
- Lessons from The Land
- Word on the street
Festival of the Wichitas
Gallery
Contact

(580) 429-3940

Sonrise Intake Application

Applicant Information

First

Middle

Last

Street Address

Street Address Line 2

City

State

Zip Code

Country

SSN*

Date of Birth*

Phone Number

Email address

Referral Source*

Support Contact Information

First

Last

Street Address

Street Address Line 2

City

State

Zip Code

Country

Email address*

Emergency Contact?*

Yes

No

Phone number

Relationship*

Applicant Demographic Information

Marital Status*

Race

Gender at Birth*

Current Housing

Eye Color*

Primary Language*

Employed?*

Yes

No

Education Completed

Work Skills

Date Last Worked

Number of Children

Children being cared for by

Are you aware that you will not generate any income while you are at this center?*

Yes

No

Do you have a valid drivers license?*

Yes

No

Addiction Profile

Addiction Type:*

Frequency of Use:

Drug Use

Drug of Choice?*

Yes

No

Drug Use Start Date:

Drug Last Used:

How was/is drug taken

Other Info:

Previous Treatments

Treatment Type:

Treatment Start Date:

Treatment End Date:

Center Name:

Other Info:

Faith Profile

Do you have a Fatih or Religious Affiliation?*

Yes

No

Faith Type:

Denomination:

Are you born again?

Yes

No

Are you spirit filled?

Yes

No

Do you attend church?

Ye

No

Current Church:

Pastor's First / Last Name

Last

Medical History

Current Medications:

History of developmental issues such as learning disabilities.

Allergies:

Physician's First / Last Name

Last

Physician's Phone Number

Do you use tobacco?

Yes

No

Will you need to detox?

Yes

No

What is the condition of your teeth?

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Quick Links

Home
The Program
- Application
GSNL Enhancements
- Lessons from The Land
- Word on the street
Festival of the Wichitas
Gallery
Contact

19792 Cache Rd

Cache, OK

73527

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