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Referral Information
Person Completing Form
Client Information
Drug(s) of Choice & Usage Patterns
Name of Drug:
Age of first use:
Date of last use:
How much/often?
Alcohol/Drug Treatment History
Dates of treatment:
Did you complete the treatment program?
Type of treatment: (residential, outpatient, inpatient, etc.)
Current Medications
Name of Medication:
Dosage & Frequency:
Prescribing Physician:
Reason for Medication:

Medical & Psychiatric Information

Employment & Financial Information

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For more information about financial arrangements at Clearview Recovery call toll-free (800) 845-8918.