| Last Name: |
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| First Name: |
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| SS#: |
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| Address: |
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| City: |
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| State: |
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| Zip Code: |
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My Drivers Lic is currently valid |
| If yes, what state?: |
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| DL# / ID#: |
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| Class of Lic: |
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| Age: |
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| Date of Birth: |
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| Place of Birth: |
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| Hieght: |
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| Weight: |
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| Race: |
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| Eye color: |
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| Birth marks and tattoos: |
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| personal phone or cell: |
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| Emergency Contact Information: |
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| Referred by: |
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Mother living? |
| Describe your relationship with her: |
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Father living? |
| Decribe present relationship with him: |
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| Marital status of mother: |
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| Marital status of father: |
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| Mothers address: |
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| Mothers City: |
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| Mothers state: |
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| Mothers Phone: |
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| Mothers legal Name: |
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| Fathers legal name: |
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| Fathers address: |
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| Fathers city: |
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| Fathers state: |
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| Fathers phone: |
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| who were you raised by?: |
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| How many brothers?: |
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| How may sisters?: |
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| What number are you in birthorder?: |
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Check if adopted |
| current marital status: |
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| Wife's Name: |
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| Wife's address: |
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| Wife's Phone: |
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| Number of times been married?: |
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| How many children do you have?: |
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| Child support owed?: |
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| Name/ages of your children: |
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| Have you participated in homosexual acts?: |
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| Do you smoke?: |
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| Do you consume Alcoholic beverage?: |
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| How much / How often?: |
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| Are you an Alcoholic?: |
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| Do you / Have you used drugs?: |
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| What kind? How long?: |
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| What age did you start using?: |
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| Current drug of choice?: |
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| Longest period sober/clean?: |
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| Have youreceived prior treatment?: |
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| List where you received treatment: |
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| Last grade completed?: |
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| college/trade school status: |
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| Military service?: |
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| How long?: |
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| Type of discharge: |
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| Reason for discharge: |
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| Name of Last Employer / dates/duties: |
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| Reason for leaving: |
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| Previous Employer dates/duties: |
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| Reason for leaving: |
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| Machines, equipment, tools you have experience with...: |
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| Ever received Workmans Compensation? Explain yes: |
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| Have you been in prison?: |
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| Most recent prison: |
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| Are you on Probation?: |
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| Felony or Mis?: |
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| Probation Officers name: |
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| Probation phone and location: |
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| Offense?: |
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| Upcoming court dates?: |
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| Proposed outcome?: |
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| Attorneys name: |
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| Attorneys phone: |
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| Attorneys address / city / state: |
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| List charges, convictions, depositions received in your lifetime: |
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| Vocational training received during incarcerated?: |
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| Describe current health status: |
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| List and describe any medical problems: |
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| List and describe any current medications: |
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| List any major illnesses or operations you have had? Dates?: |
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| Have you ever been committed to a psychiatric hospital? When?: |
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| Ever had suicidal thoughts? Attempts? Dates?: |
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| Do you have any medical insurance? If so, what kind?: |
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| Do you have HIV or Hepatitus?: |
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| Date last tested for HIV?: |
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| Date last tested for Hepatitis?: |
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| Type tested for?: |
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| Are you or have you ever been a church member?: |
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| If yes, what church? Location?: |
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| What Denomination?: |
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| Pastors phone / contact info?: |
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| How long were you a member?: |
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| Do you believe in God?: |
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| Do you pray to God?: |
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| Are you Born-Again?: |
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| Do you read the Bible?: |
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| Do you believe the Bible is Gods Word?: |
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| When did you become a Believer?: |
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I am active |
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I am self-confident |
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I am persistant |
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I am nervous |
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I am hard working |
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I am patient |
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I am impulsive |
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I am moody |
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I am often depressed |
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I am excitable |
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I am imaginative |
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I am calm |
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I am serious |
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I am easy-going |
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I am shy |
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I am good-natured |
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I am an introvert |
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I am likeable |
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I am a leader |
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I am quiet |
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I am submissive |
| Describe yourself: |
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| Are you desperate to change?: |
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| Are you willing to seek Jesus Christ as your answer?: |
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| Best way to contact you: |
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