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Placement Form
Personal Information
* Full Name
* Phone
Email
Current Residency
Address
City
State
Zip
Insurance Information
Insurance Type
ID number
Group number
Other Important Information
Date of Birth
Age
Gender at Birth
Marital Status
Single
Married
Divorced
Children Names
(seperate with a comma)
Are you pregnant?
No
Yes
Do you have any pending DHR cases?
No
Yes
If yes to above question explain:
Are you a sex offender?
No
Yes
Do you have any pending court cases?
No
Yes
Do you have any pending warrants for your arrest?
No
Yes
Financial
Disability Payments
List Disability
Welfare
Social Security Payments
Unemployment
Safety
Emergency Contact
Emergency Phone
Do you have Siezures?
No
Yes
If yes, last occurrence
Suboxone Use
No
Yes
What substances will you be detoxing from?
Date of last use of substance:
Diagnosed Medical Conditions:
(seperate with a comma)
Medications:
(seperate with a comma)
Have you ever made a suicide attempt?
No
Yes
Have you ever purposely harmed yourself (cutting, burning, or other)?
No
Yes
Do you have a valid driver's license?
No
Yes
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