County last resided
Social Security #
Age
Phone
Gender
Other
Other
Drivers license number
Family size
Number of children
Ages/Gender
Children(s) placement
Do you have an open DCS case?
If yes, DCS FCM Name & Email
Branch
Discharge status
Name
Relationship
Phone
Name
Relationship
Phone
Sobriety date
Length of longest sobriety
Date
Other drugs used
Frequency of use?
How do you use?
Age of first use?
Referral name/organization
If yes: Insurance provider
Insured Name
Insured DOB
Group#
Insurance#
If yes, when?
Date of your last physical examination
Physician's Name/Clinic
If yes, for what condition?
If yes, what are they?
Date
(+,-)
Date
(+,-)
Date
(+,-)
Date
(+,-)
Name of medication
Reason for medication
Name of medication (copy)
Reason for medication (copy)
Name of medication (copy)
Reason for medication (copy)
Name of medication (copy)
Reason for medication (copy)
Name of medication (copy)
Reason for medication (copy)
Name of medication (copy)
Reason for medication (copy)
Name of medication (copy)
Reason for medication (copy)
Name of medication (copy)
Reason for medication (copy)
If yes, please list
If yes, therapist's name/contact
If yes, what type of disorder?
When is the last time you engaged in eating disorder behaviors?
If yes, have you thought about how, when or where this would occur?
If yes, current partner, Name
Address
Phone#
Length of relationship
Substance use?
Date
Charge
Resolution
Date (copy)
Charge (copy)
Resolution (copy)
Date (copy) (copy)
Charge (copy) (copy)
Resolution (copy) (copy)
Date (copy) (copy)
Charge (copy) (copy)
Resolution (copy) (copy)
Date (copy) (copy)
Charge (copy) (copy)
Resolution (copy) (copy)
Please list
County of Parole or Probation
Probation Officer Name
If yes, when?
If yes, what was the first name of that person?
Date
Place of employment
Hourly rate
From & To
Company
Position
Why did you leave?
From & To
Company
Position
Why did you leave?
From & To (copy)
Company (copy)
Position (copy)
Why did you leave? (copy)
From & To (copy)
Company (copy)
Position (copy)
Why did you leave? (copy)