First Name:Client first name
Last Name:Client last name
Phone Number:Client phone
Email:Client email
Gender: Client gender
Date of Birth: Client birthdate
Social Security Number: SSN
Previous Address: Client Address
City: Client City
State:Client State
Zip:Client Zip
Ethnicity:Client ethnicity
Substance of Choice: Client substances of choice
Date of Last Use: Text field
Are you on probation? If Yes, Name of Agent: Probation
Medications: Medication
Maritial Status: Client marital status
Tribal Affiliation: Text field
Are you a veteran: Client veteran status
Emergeny Contact: Family Members
Have you been to treatment: TreatmentCenterHistory
Signature: Signature