Online Assessment Form
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Area
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Macomb County
Bay-Midland-Saginaw Counties
Genesee County
Lapeer County
New York - Hudson Valley Area
Oakland County
Wayne County
Wayne County - Downriver
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Gender
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D.O.B.
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What type of service are you needing?
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Detox
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First Name
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Last Name
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Email Address
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Phone Number
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Address
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City
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County
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State
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Zip Code
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Who are you looking for services for?
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Volunteer Angel on behalf of participant
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How did you hear about the Hope Not Handcuff Program?
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Do you currently have health insurance
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Carrier
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Insurance Number
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Mental Health Diagnosis?
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All information is kept confidential and is property of Families Against Narcotics for Hope Not Handcuffs Recovery Program a 501c3 non profit.
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