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Keaton's Place - Client Worksheet
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* Indicates required question
Email
*
Your email
Today's date
*
MM
/
DD
/
YYYY
Last name
*
Your answer
First name
*
Your answer
Middle Initial
*
Your answer
Gender
*
Female
Male
Trans
Unspecified
Race
*
African American
Caucasian
Asian
Middle-Eastern
Hispanic/Latinx
Native American
Pacific Islander
Prefer not to say
Other:
Have you ever served in the military?
*
Yes
No
Honorary discharged
Date of birth
*
MM
/
DD
/
YYYY
Do you currently live in Randolph County?
*
Yes
No
Do you have a valid drivers license or an NC ID with you?
*
Drivers License
NC ID
I have a picture of one of these things on my phone
I do not have a copy of this
Do you have anything with your name and current address on it? (power bill, cell phone bill, etc.)
*
Yes, I do
No, I don't
Are you Homeless?
Your answer
Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip code
*
Your answer
Telephone number
*
Your answer
Emergency contact
*
Your answer
Telephone number
*
Your answer
Why are you visiting Keaton's Place today? (Check all that apply)
*
Seeking treatment/services for my personal substance abuse
Seeking treatment/services for a loved one's substance abuse
I am in recovery but I would benefit from out-patient services or other support
Required
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