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Client Intake Form

First Name

Last Name

Phone

City

State

Who are you filling this out for?

What is the primary reason you are reaching out?

Relationship to you

Where do they currently live?

Relationship to you (other family member)

Relationship to you (other)

Where do they currently live? (other)

Age of the person needing help

Date of Birth

Employment status

Employment status (other)

Do you have identification?

Which substance(s) are involved?

How would you describe the current situation?

Has this person been in treatment before?

What is the insurance situation?

How urgent is this?

If you or someone you know is in immediate danger, please call 911 or the 988 Suicide & Crisis Lifeline.
You can still submit this form — our team will prioritize your request.

Upload a photo of the insurance card (optional)

Maximum file size: 268.44MB

Pertinent history

Please include anything else such as mental health concerns, PTSD and its source, other co-occurring health conditions, or legal issues — whether current or past.

Anything else you would like us to know?

0 of 500 max characters

SMS consent

By submitting your phone number, you authorize Recovery United to send you text messages (including account alerts and appointment reminders). Consent is not a condition of purchase. Message and data rates may apply. Message frequency varies. Text STOP to unsubscribe at any time or HELP for support. View our Privacy Policy and Terms of Service.

If you are human, leave this field blank.