Ready to Join The Phoenix House? Name * First Name Last Name Email * Phone (###) ### #### Age Referral source Co-occurring Diagnosis Prior Treatment Recovery Residence History Drug(s) of Choice Any IV Opiate Use Yes No Recovery Time Medications History of Self-Harm Yes No Recent Suicidal ideation Yes No Recent Homicidal ideation Yes No Relationship Status Single In a Relationship Married Children Work Experience Do you have the support of your family? Yes No TB Test? must bring copy of results Yes No Ever been arrested, convicted, or questioned for any violent or sexual crimes Yes No Any outstanding warrants Yes No Are you legally mandated to be here? Yes No Legal Issues? Anything Else We Should Know? Thank you!
