General
Name:Client first name Client last name
Date Of Birth: Client birthdate
Social Security Number:SSN
Phone Number:Client phone
Email:Client email
Address:Client Address City:Client City Mo:Client State Zip Code: Client Zip
Client race
Client ethnicity
Client marital status
Client veteran status
Who reffered you to Rise Up Text field
Income
EmploymentHistory
Emergency Contact
Contact
Criminal History
Probation
Current Physician
Therapist/Clinician
Insurance Information
Insurances
Current Medical Diagnosis
(Please include physical and Mental Health Diagnosis)
Client diagnosis
Client allergies
Medication
Recovery History
Client substances of choice
Client kinds of meetings attended
SponsorInformation
Client sponsor
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