{"id":21624,"date":"2015-12-10T01:02:17","date_gmt":"2015-12-10T01:02:17","guid":{"rendered":"http:\/\/wayoflife:8888\/wp\/?page_id=21624"},"modified":"2021-11-16T13:04:51","modified_gmt":"2021-11-16T18:04:51","slug":"intake","status":"publish","type":"page","link":"https:\/\/www.hustlehope.com\/intake\/","title":{"rendered":"Online Intake"},"content":{"rendered":"<section class=\"wpb-content-wrapper\"><p>[vc_row row_type=&#8221;row&#8221; use_row_as_full_screen_section=&#8221;no&#8221; type=&#8221;grid&#8221; text_align=&#8221;left&#8221; background_color=&#8221;#ffffff&#8221; padding_top=&#8221;50&#8243; padding_bottom=&#8221;100&#8243; css_animation=&#8221;&#8221;][vc_column]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f21706-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/wp-json\/wp\/v2\/pages\/21624#wpcf7-f21706-o1\" method=\"post\" class=\"wpcf7-form init default\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"21706\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.9.3\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f21706-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<h3>Contact Information\n<\/h3>\n<hr style=\"border:0;height:0;border-top: 1px solid rgba(0, 0, 0, 0.1);border-bottom: 1px solid rgba(255, 255, 255, 0.3);margin-bottom:30px\" \/>\n<p><strong>Your Name <span class=\"required-star\">*<\/span><\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span>\n<\/p>\n<p><strong>Street Address <span class=\"required-star\">*<\/span><\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"street-address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"street-address\" \/><\/span>\n<\/p>\n<p><strong>City <span class=\"required-star\">*<\/span><\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"city\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"city\" \/><\/span>\n<\/p>\n<p><strong>State <span class=\"required-star\">*<\/span><\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"state\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"state\" \/><\/span>\n<\/p>\n<p><strong>Zip Code <span class=\"required-star\">*<\/span><\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"zip-code\"><input size=\"40\" maxlength=\"5\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"zip-code\" \/><\/span>\n<\/p>\n<p><strong>Phone <span class=\"required-star\">*<\/span><\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"telephone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"telephone\" \/><\/span>\n<\/p>\n<p><strong>Your Email <span class=\"required-star\">*<\/span><\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span>\n<\/p>\n<p>&nbsp;\n<\/p>\n<h3>Emergency Contact\n<\/h3>\n<hr style=\"border:0;height:0;border-top: 1px solid rgba(0, 0, 0, 0.1);border-bottom: 1px solid rgba(255, 255, 255, 0.3);margin-bottom:30px\" \/>\n<p><strong>Contact Name <span class=\"required-star\">*<\/span><\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-contact-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"emergency-contact-name\" \/><\/span>\n<\/p>\n<p><strong>Contact Number <span class=\"required-star\">*<\/span><\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-contact-number\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"emergency-contact-number\" \/><\/span>\n<\/p>\n<p><strong>Contact Relationship <span class=\"required-star\">*<\/span><\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-contact-relationship\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"emergency-contact-relationship\" \/><\/span>\n<\/p>\n<p>&nbsp;\n<\/p>\n<h3>Drug\/Alcohol & Treatment History\n<\/h3>\n<hr style=\"border:0;height:0;border-top: 1px solid rgba(0, 0, 0, 0.1);border-bottom: 1px solid rgba(255, 255, 255, 0.3);margin-bottom:30px\" \/>\n<p><strong>Substances Abused <span class=\"required-star\">*<\/span><\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"substances\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"substances[]\" value=\"Heroin\" \/><span class=\"wpcf7-list-item-label\">Heroin<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"substances[]\" value=\"Crack\" \/><span class=\"wpcf7-list-item-label\">Crack<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"substances[]\" value=\"Oxycontin\" \/><span class=\"wpcf7-list-item-label\">Oxycontin<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"substances[]\" value=\"Alcohol\" \/><span class=\"wpcf7-list-item-label\">Alcohol<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"substances[]\" value=\"Marijuana\" \/><span class=\"wpcf7-list-item-label\">Marijuana<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"substances[]\" value=\"Percoset\" \/><span class=\"wpcf7-list-item-label\">Percoset<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"substances[]\" value=\"Pills\" \/><span class=\"wpcf7-list-item-label\">Pills<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"substances[]\" value=\"Meth\" \/><span class=\"wpcf7-list-item-label\">Meth<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"substances[]\" value=\"Cocaine\" \/><span class=\"wpcf7-list-item-label\">Cocaine<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"substances[]\" value=\"Ketamine\" \/><span class=\"wpcf7-list-item-label\">Ketamine<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"substances[]\" value=\"Ecstasy\" \/><span class=\"wpcf7-list-item-label\">Ecstasy<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"substances[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"substances[]\" value=\"Not Sure\" \/><span class=\"wpcf7-list-item-label\">Not Sure<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><strong>Sobriety Date <span class=\"required-star\">*<\/span><\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"sobriety-date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"sobriety-date\" \/><\/span>\n<\/p>\n<p><strong>Previous Treatment Centers <span class=\"required-star\">*<\/span><\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"treatments\"><textarea cols=\"40\" rows=\"10\" maxlength=\"250\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"treatments\"><\/textarea><\/span>\n<\/p>\n<p><strong>Previous Sober Living <span class=\"required-star\">*<\/span><\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"sober-livings\"><textarea cols=\"40\" rows=\"10\" maxlength=\"250\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"sober-livings\"><\/textarea><\/span>\n<\/p>\n<p>&nbsp;\n<\/p>\n<h3>Legal Information\n<\/h3>\n<hr style=\"border:0;height:0;border-top: 1px solid rgba(0, 0, 0, 0.1);border-bottom: 1px solid rgba(255, 255, 255, 0.3);margin-bottom:30px\" \/>\n<p><strong>On Parole <span class=\"required-star\">*<\/span><\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"on-parole\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"on-parole\"><option value=\"No\">No<\/option><option value=\"Yes\">Yes<\/option><\/select><\/span>\n<\/p>\n<p><strong>On Probation <span class=\"required-star\">*<\/span><\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"on-probation\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"on-probation\"><option value=\"No\">No<\/option><option value=\"Yes\">Yes<\/option><\/select><\/span>\n<\/p>\n<p><strong>Charges Pending <span class=\"required-star\">*<\/span><\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"charges-pending\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"charges-pending\"><option value=\"No\">No<\/option><option value=\"Yes\">Yes<\/option><\/select><\/span>\n<\/p>\n<p><strong>Registered Sex Offender <span class=\"required-star\">*<\/span><\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"registered-sex\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"registered-sex\"><option value=\"No\">No<\/option><option value=\"Yes\">Yes<\/option><\/select><\/span>\n<\/p>\n<p><strong>If Yes Above, Please Describe<\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"legal-if-yes\"><textarea cols=\"40\" rows=\"10\" maxlength=\"250\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"legal-if-yes\"><\/textarea><\/span>\n<\/p>\n<p>&nbsp;\n<\/p>\n<h3>Medical Information\n<\/h3>\n<hr style=\"border:0;height:0;border-top: 1px solid rgba(0, 0, 0, 0.1);border-bottom: 1px solid rgba(255, 255, 255, 0.3);margin-bottom:30px\" \/>\n<p><strong>Have Medical Insurance <span class=\"required-star\">*<\/span><\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"medical-insurance\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"medical-insurance\"><option value=\"No\">No<\/option><option value=\"Yes\">Yes<\/option><\/select><\/span>\n<\/p>\n<p><strong>Insurance Provider<\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"insurance-provider\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"insurance-provider\" \/><\/span>\n<\/p>\n<p><strong>Prescription Medications <span class=\"required-star\">*<\/span><\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"prescriptions\"><textarea cols=\"40\" rows=\"10\" maxlength=\"250\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"prescriptions\"><\/textarea><\/span>\n<\/p>\n<p><strong>Doctor's Name<\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"doctor\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"doctor\" \/><\/span>\n<\/p>\n<p><strong>Doctor's Phone<\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"doctor-telephone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"doctor-telephone\" \/><\/span>\n<\/p>\n<p><strong>Previous Suicide Attempt<\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"suicide-attempted\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"suicide-attempted\"><option value=\"No\">No<\/option><option value=\"Yes\">Yes<\/option><\/select><\/span>\n<\/p>\n<p><strong>Allergies\/Conditions <span class=\"required-star\">*<\/span><\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies\"><textarea cols=\"40\" rows=\"10\" maxlength=\"250\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"allergies\"><\/textarea><\/span>\n<\/p>\n<p>&nbsp;\n<\/p>\n<h3>Employment Information\n<\/h3>\n<hr \/>\n<p><strong>Currently Employed <span class=\"required-star\">*<\/span><\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"employed\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"employed\"><option value=\"No\">No<\/option><option value=\"Yes\">Yes<\/option><\/select><\/span>\n<\/p>\n<p><strong>Able to Work <span class=\"required-star\">*<\/span><\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"able-work\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"able-work\"><option value=\"No\">No<\/option><option value=\"Yes\">Yes<\/option><\/select><\/span>\n<\/p>\n<p><strong>Employer's Name<\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"employer\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employer\" \/><\/span>\n<\/p>\n<p><strong>Supervisor's Name<\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"supervisor\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"supervisor\" \/><\/span>\n<\/p>\n<p><strong>Shift Start Time<\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"shift-start\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"shift-start\" \/><\/span>\n<\/p>\n<p><strong>Shift End Time<\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"shift-end\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"shift-end\" \/><\/span>\n<\/p>\n<p>&nbsp;\n<\/p>\n<h3>Acceptance & Verification\n<\/h3>\n<hr style=\"border:0;height:0;border-top: 1px solid rgba(0, 0, 0, 0.1);border-bottom: 1px solid rgba(255, 255, 255, 0.3);margin-bottom:30px\" \/>\n<p style=\"margin-bottom:30px\"><span class=\"wpcf7-form-control-wrap\" data-name=\"acceptance\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"acceptance\" value=\"1\" aria-invalid=\"false\" \/><\/span><\/span><\/span> I hereby certify that the information above is true and accurate and that Way of Life, LLC may utilize the information in rendering a decision on my acceptance into the sober living program they facilitate. <span class=\"required-star\">*<\/span>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit Form\" \/>\n<\/p><p style=\"display: none !important;\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"228\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n[\/vc_column][\/vc_row]<\/p>\n<\/section>","protected":false},"excerpt":{"rendered":"<p>[vc_row row_type=&#8221;row&#8221; use_row_as_full_screen_section=&#8221;no&#8221; type=&#8221;grid&#8221; text_align=&#8221;left&#8221; background_color=&#8221;#ffffff&#8221; padding_top=&#8221;50&#8243; padding_bottom=&#8221;100&#8243; css_animation=&#8221;&#8221;][vc_column][\/vc_column][\/vc_row]<\/p>\n","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"full_width.php","meta":{"footnotes":""},"yoast_head":"<!-- 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