LLBH Provider referral/Client Intake Form

Please correct the errors described below.
Please provide locations, dates, reason for hospitalization and treatment provided.
Please provide current and past use. What substance you use, frequency, intensity, and duration usage.
Please provide name, phone number and address for the provider.
Please provide name of medications, dosage, and reason.
Such as DCF, DYS, Probation, DMH, etc?
    Please upload a file

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