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2 - Client Information

Community & Family Resources
Phone 515-576-7261
Fax 515-955-7628
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
* Date
Preferred Name    (to be called)
* Race
* Ethnicity
* Marital Status
* Employment Status
Employer
* Last Grade Completed (in years)
Emergency Contact
Name:
Address:
Address Line 2:
City: State: Zip Code:
Phone: (Home)
  
(Business)
   (Cell)
Relationship:
Email:
Attorney
DHS
Probation Officer
* Number of non-treatment substance abuse related hospitalizations in the last 6 months    
* Any allergies or special precautions? (medications, food, latex, environmental)
Yes   No  
If yes, what are they? (allergies)
* Have you ever tested positive for HIV?
* Are you pregnant?
* Head Injury? (Past/Current/None)
Past   Current   None  
Are you concerned about your mental health, gambling, alcohol use or drug use?
How important is it to address your mental health, gambling or substance use?
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