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Email
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Address
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Do you have Children
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Do you have Care for them
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How did you find us?
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Have you completed 72hr Detox
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Are you on any Medications?
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Please list ALL your medications
Have you been Diagnosed with Mental Health issues
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Please give details-when you were diagnosed, who is your doctor.
Have you been on your Medications for 3 or more Months
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Are you Pregnant?
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Reason for seeking Recovery Treatment
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List any previous treatments you participated and for how long
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Current Legal Issues, please list all issues.
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When was your last use date
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Are you involved with any restraining orders, against you or against another party. Please give very brief details
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