Consumer Information
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Email *
Consumer Number
Name
M Number
Social Security Number
Diagnostic Code
Phone
Date of Birth
MM
/
DD
/
YYYY
BHC
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Last Chance
MM
/
DD
/
YYYY
Detection
Intake Date
MM
/
DD
/
YYYY
Battle Buddy
3rd Month Date
MM
/
DD
/
YYYY
Letter Notification
MM
/
DD
/
YYYY
Housing Fee
Number of Months
Total Amount
Past Due
Paid to Date
House
Room
Bed
Children
Housing Discharge Date
MM
/
DD
/
YYYY
Clinical Discharge Date
MM
/
DD
/
YYYY
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