StepByStep Intake Form

Please Complete the form with as much information as possible. If you have any question, please feel free to call our office at 678-377-2323 M-F 10:00am. - 4:00pm.

First Name

Middle Name

Last Name

Address Line 1

Address Line 2

City

State

Zip Code

1st line Phone

2nd Phone Line

Email Address:

Date of Birth

Age

Sex

Race/Ethnic Group

Valid State ID, YES OR NO (What Kind)

Last Grade Completed

Marital Status

Name of Spouse or Significant other

Number of Dependents, Age, Sex

Place of last employment & Last annual income

Have you been in Treatment before/Where?

Do you have finances or help paying 870.00 Program admission fee?

Legal Status (i.e. probation, parole, case pending)

Are you mandate to a program?

Probation/ Parole Name

Attorney or Bails Bond Name and Number

Any Upcoming Court Date on Application

Are you a registered sex offender?

Problem Substance (i.e. Alcohol, cocaine, meth, ect.)

Date of Last Substance Used

All substance last used: (All)

What type of medication are you currently taking?

Do you have any mental or physical conditions which would prevent you from obtaining employment?

Name and phone # of closest relative

How did you hear about StepByStep Recovery, Inc?

(Now or Have) you in the last 10 days been in another program, incarcerated or other if so where

Do you have transportation?

StepByStep Intake Form

Thank you!

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