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Intake Survey
Personal Information
Name
*
Cell
*
date-of-birth
*
dl-number
*
exp-ate
*
Emergency Contact
Name
*
Relationship
*
Cell
*
Home/work:
*
Employed
*
Employer:
*
Home/Work
*
Income-Status
*
Some Questions
Have you ever had suicidal or homicidal thoughts?
*
Yes
No
Are you on a sex offender registry?
*
Yes
No
Are you on probation?
*
Yes
No
Are you court ordered?
*
Yes
No
Have you ever attempted suicide?
*
Yes
No
Do you have any open warrants?
*
Yes
No
Officer
*
Judge
*
Current Legal Issues
Do you have any legal issues you need help with dealing currently?
*
Yes
No
List any medical or mental health conditions:
*
Previous treatment and date:
*
What is your drug of Choice?
*
List all your medications:
*
Please note: AEY Housing LLC does not accept Sexual Predators.
NOTICE TO RECIPIENT OF INFORMATION: This information has been disclosed to you from records protected by Federal Confidentiality Rules (42 CFR Part 2). The Federal Rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains, or as otherwise permitted by 42 CFR Part 2. This information is also protected by Florida State Statute. As per Florida State Statute, this information shall be confidential and may not be further disclosed without written informed consent of the person to who it pertains.
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