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  • Your Info
  • History
  • Personal

Name and Info

Name

Phone Number

Date of Birth

Current Living Situation

Usage

Clean Date

Drug of Choice

Currently in treatment?

If yes, admit date

If yes, where

If yes, are you

History

Have you ever been to a halfway house

If yes, where and when

What do you hope to obtain from moving into a recovery residence?

Personal

Currently Employed

Medical Issues

Medications

Psychiatric Diagnoses

Legal Issues

Ever been charged with violent crimes?

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