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[DOCX File]FULL ASAM ASSESSMENT - ADULT
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Amy has a 5 yr history of opioid use, beginning with prescription opioids and progressing to mixed prescription and heroin use. She has attempted multiple programs to try and manage her use and despite these attempts and escalating harmful consequences (loss of employment and independent housing), she continues to use.
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[DOC File]Family Group Sheet (Please PRINT
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22. BURIED AT: Write the cemetery name and place were the wife was buried using the proper place format: Town, County, State, Country. Leave this box blank if the she is still living. 23. FATHER: Write the full birth name of the wife's father using the proper name format: First, "Nickname", Middle, LAST. Include the birth date and place if ...
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[DOC File]Hazard Communication Program
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manufacturer’s name, address and telephone numbers. Each project manager or other designated person will have the responsibility of assuring that all labels are affixed on containers properly. As new products arrive at the project, the project manager or other designated person will …
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[DOC File]Stormwater Control Inspection and Maintenance Log
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Facility Name. Address. Begin Date End Date. ... Use additional log sheets and/or attach extended comments or documentation as necessary. Submit a copy of the completed log with the annual independent inspectors’ report to the municipality, and start a new log at that time.
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[DOC File]Student Information Sheet
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Title: Student Information Sheet Author: default Last modified by: default Created Date: 8/4/2007 7:56:00 PM Company: Bibb BOE Other titles: Student Information Sheet
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[DOC File]CLIENT PERSONAL DATA SHEET
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Universal Workshop seeks access to information on Employee's Name. This information will be used to supplement the employee application, referral form, and consumer information form. By signing this form the employee (guardian) gives Universal Staff permission to obtain information from the Department of Mental Health: The St. Louis Regional ...
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[DOCX File]Food Pantry Template.docx - AIRS
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PROGRAM NAME: Include only if pantry has a specific name; do not simply repeat agency name. DESCRIPTION. Describe items offered, any special information about service (such as “client choice” formats), whether a referral is required, whether an appointment is required, and (finally) whether the service as a limited or open service area.
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CREDIT CARD AUTHORIZATION FORM
Authorization for Credit Card Use. PRINT AND COMPLETE THIS AUTHORIZATION AND RETURN. All information will remain confidential Name on Card: _____ Billing Address: _____
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[DOC File]INSPECTION AND TESTING FORM
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PROPERTY NAME (USER) Name: Address: Owner Contact: Telephone: APPROVING AGENCY. Contact: Telephone: SERVICE. Weekly Monthly Quarterly. Semiannually Annually. Other (Specify) Last Date System Had Any Service Performed: Last Date That Any Software or Configuration Was Revised: ALARM-INITIATING DEVICES AND CIRCUIT INFORMATION ...
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[DOC File]PARTICIPANT REGISTRATION/RELEASE FORM
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Additional registration information, ie., full printed name and address, phone, email, emergency contact, and other information may be useful for the administration of the event. [Disclaimer: This template for a “Participant Registration Release Form” is provided as a template only, but may be used freely to develop waiver/releases for a ...
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Printable name and address sheets