CONFIDENTIALITY: The information you give below will be held in strict confidence and will be used for establishing your file. Any misrepresented or false information places you at risk of being re-evaluated (at your cost) or discharged.
Date(s): 1st:
Date(s): 2nd:
Date(s): 3rd:
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How many brothers and sisters do you have?
How many step-brothers and sisters do you have?
History of Employment: (start from present)
How often have you experienced each of the following in the last two months?
want the Referral Source notified of the results of the evaluation.
Please answer the following questions on the basis of how you have drank alcohol or used drugs In the past 10 years. If you have not been drinking for a length of time, there will be a space to list that in. We need to know how you have drank alcohol or used drugs in the past
3315 East Ponce de Leon Ave. Scottdale, GA. 30079
Phone: 678-671-2384 Cell: 404-323-7370 Fax: 678-712-5384
pamelaweeks@counselingsecure.com
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