Online intake form
We are so proud of you for seeking a better future for yourself. You will not believe the amazing things waiting for you when you enter recovery. Please fill out this form and our Intake Director will get with you soon to finalize your placement. If you would rather do this over the phone, you can just call (918) 864-2719.
Sign in to Google to save your progress. Learn more
Email *
First Name *
Last Name *
Birthdate *
MM
/
DD
/
YYYY
Gender *
Children? *
Phone Number *
Is this your personal number? *
Permission to leave a message? *
Email
City
State
Zip Code
Do you have your state ID?
Clear selection
Do you have your birth certificate?
Clear selection
Do you have a social security card?
Clear selection
Are you able to work?
Clear selection
Are you healthy?
Clear selection
Are you pregnant?
Clear selection
Do you take any meds daily?
Clear selection
If yes to medications, please list them below:
Do you have any pending criminal court charges?
Clear selection
State where your cases are:
Court Dates:
Charges:
Are you on probation?
Clear selection
Are you on parole?
Clear selection
Are you a registered sex offender or do you need to register for a sex offense?
Clear selection
Permission to enter rehab?
Clear selection
Do you need transportation to rehab?
Clear selection
Drug of Choice? *
Date of last use? *
MM
/
DD
/
YYYY
List all drugs used: *
Do you need detox? *
Are you in detox or have you recently completed detox? *
Do you have health insurance? *
Are there any other details we need to complete your placement? *
How did you hear about Reckless? *
Have you called the Reckless Saints of Nowhere's Treatment Placement Hotline?
Clear selection
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Reckless Saints of Nowhere, Inc.. Report Abuse
Google Forms