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Full Name
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Street Address
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City
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State
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ZIP
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Primary Phone
Home Phone
Email Address
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Birth Date
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Veteran
Yes
No
If Yes, What Branch?
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Are you on probation or parole?
Yes
No
Probation/Parole Location?
PO's Name
PO's Phone Number
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Do you currently have any open cases or warrants? If yes, please explain.
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I'm taking the following medication(s)
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Drug(s) of Choice?
Date of Last Use
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Referred By
Entry Date
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Lived at New Beginnings Before?
Yes
No
If Yes, When?
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1. How old were you when you first used drugs/drank?
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2. Have you ever been in a Drug/Alcohol Treatment Center? When?
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3. Have you ever been in a halfway house? When?
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4. What is your highest level of education?
College/Univesity
High School Graduate
GED
Other
If Other, please describe.
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5. Have you ever been in prison? How many times?
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6. Have you ever been ARRESTED for a sex crime or arson?
Yes
No
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7. Where did you live before moving here? (City/State)
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8. Are you employed? If yes, what kind of work do you do?
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9. What are your means of transportation?
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10. What is your source of income?
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11. Are you:
Married
Single
Divorced
Separated
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12. Have you ever received any DUI's or DWI's? If yes how many?
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13. What kind of problems has drinking and/or drug use caused you?
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14. Are you prejudiced towards any group or race?
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15. What kind of medical problems (physical or emotional) do we need to know about you?
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16. When is the last time you were checked for a sexual transmitted disease?
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17. Have you ever engaged in unprotected sex?
Yes
No
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18. When is the last time you were checked for blood borne diseases?
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