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Name and InfoNamePhone NumberDate of BirthCurrent Living SituationUsageClean DateDrug of ChoiceCurrently in treatment?If yes, admit dateIf yes, whereIf yes, are youHistoryHave you ever been to a halfway houseIf yes, where and whenWhat do you hope to obtain from moving into a recovery residence?PersonalCurrently EmployedMedical IssuesMedicationsPsychiatric DiagnosesLegal IssuesEver been charged with violent crimes? |
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