Client Information Form Fields marked with an * are required Initial Intake Form "*" indicates required fields Your name* Your Relationship to Potential Client* Your Phone Number* Potential Client's Full Legal Name* Potential Client Email* Date of Birth* MM slash DD slash YYYY Parent's Current Address* Who is the potential client living with right now?* Is the potential client in treatment at this moment?* If yes, where?* How did you hear about Rising Roads Recovery?* To the best of your knowledge: What medications is the potential client on?* To the best of your knowledge: Do you know what the potential client drinks and/or what kind of drugs they are using or have used?* To the best of your knowledge: How long has the potential client been abusing the items above?* Do you know if the potential client has had any suicide attempts or suicidal thoughts? Has the potential client engaged in any self-harm behaviors in the past or are they currently self harming?* If so, when was the last attempt at suicide or self harm?* To the best of your knowledge: Are there any medical issues Rising Roads should be aware of?* If so, please list all medical issues you are aware of* Is there anything you believe Rising Roads Recovery should know?* Are you wanting to use insurance to offset the cost of treatment?* Do you have any questions for Rising Roads Recovery?* Security question, please answer the math question: What is 5+4?* Δ Fields marked with an * are required