Averte
Client Application
Applicant’s Name
*
Address
*
Address
Street Address Line 2
City
State/Zip
Postal / Zip Code
Phone
Cell
*
Other
Email
*
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date
Gender:
*
Marital Status
1 What are some of your hopes or dreams for your future?
*
3 What is your current situation? Where are you emotionally and physically?
*
4 Please tell us about some of your past accomplishments such as school, work, relationships, athletics, or other achievements.
*
5 What else do you like to do for enjoyment, such as music, hiking, reading, writing, etc.?
*
6 What else would you like to tell us?
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Averte
Client Application continued
Religion:
Do you need support with finding and attending religious services while in treatment?
Do you have any religious holidays, practices or cultural traditions you would like to observe while in treatment?
Signature
*
Date
*
/
Month
/
Day
Year
Date
Please verify that you are human
*
Submit
Should be Empty: