Initial Intake Application
Our purpose for the initial assessment is to gather basic information about you and the problems and pain that addiction has caused you and your loved ones. So we require that this form, ONLY be filled out by the person being assessed. if that is not an option at this moment, please contact us directly and we will be glad to help you.
Email address *
1. Full Name *
Your answer
2. Gender *
Required
3. Current Phone Number *
Your answer
4. **Emergency Contact** *
In case of an Emergency please contact... Name / Phone # / Relationship
Your answer
5. Date of Birth *
MM
/
DD
/
YYYY
6. Your Address - Most Recent *
(city, state and zip code)
Your answer
7. List of Authorized People *
By entering a person(s) name below, you herby AUTHORIZE the exchange of information between S2L Recovery and the person(s) listed below. If you do not wish to authorize anyone, please type "NONE" Enter: Full Name / City and State of Residence / Phone Number (with area code)
Your answer
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