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Referral source
*
Client name
*
Date of birth
*
Month
Month
Day
Year
Current location
*
Current treatment provider
*
MAT status
*
Currently on MAT
Previously on MAT
Not on MAT
Unknown
Transportation needs
*
No transportation needs
Needs transportation assistance
Has own transportation
Unknown
Criminal justice involvement
*
None
Current involvement
Past involvement
Unknown
Insurance
Notes
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