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Sending Authority; Are currently under the supervision of any of the following?
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State or Federal Probation Offficer
Community Sentencing
DA Supervision
Judge Authority
Drug Court
Other
Marital Status
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Do you owe Child Support
Number of Children
Military History
Military Service
Education/Work History
Job History
Drivers License or State ID
Do you have a drivers license?
Physical and Mental Health
Rate your Health Condition
Do you now or have you ever had any of the following: Please select all that apply
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High Blood Pressure
Arthritis
Heart
Back problems
Neck problems
Problems with legs
Problems with feet
Migraines
Broken bones
Liver problems/ Hepatitis
Metal in bones/ surgical implants
Glasses
Seizures
Diabetes
Carpal Tunnel Syn.
Thyroid issues
Hand issues - Broken, Surgery, Pins, Etc
Shoulder Issues
Any other medical issues please add here
List all current and previous medications and why prescribed
Have you ever been diagnosed with any Mental Health concerns?
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If yes, list conditions, any treatment programs and medicine prescribed for Mental Health
Abuse History
Age of first alcohol and drug use?
Last date alcohol or drugs used
Age when use begun problems in your life?
Please list alcohol and drugs of choice.
Have received any previous treatment for substance abuse?
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If yes, please list programs and dates; as well if you completed or not.
Please list Family history of substance abuse. Include all know relatives
Have you attended AA or NA meetings?
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Do you consider yourself to have a alcohol or drug problem?
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If yes, please explain what your willing to do about it.
Legal History
List Current Charges, Pending Charges, Attorney's Name and Number, any information to help
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