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MDRN Client
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Roster
Track Type(s)
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Initial Contact Date
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DD
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YYYY
Client's Name
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M#
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SSN
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DOB
MM
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DD
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YYYY
Drug of Choice
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Diagnostic Code
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Last Use
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DD
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YYYY
# of Kids
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Age of First Usage
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Race
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Highest Grade
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Mental Health?
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Phone #
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Email Address
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Referral Org/POC
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Emergency Contact Name
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Emergency Contact Number
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For more information,
OOH Training Department : 443.805.8927
OOH Main Office 1.855.9. OOHHOPE (1.855.966.4467)
PW@OrganiationOfHope.org
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