a Form – Client Intake Form

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Client Intake Form

    Select all DMS Programs you are participating in:
    SCRAM / GPS / Drug Patch / DUI-Court / Robocuff / SCRAMx


    Address: Apt#: Driver’s Lic #:
    City: Zip: Social Sec #:
    Cell Phone: Home Phone: Work Phone:
    E-mail Address: D.O.B:
    How did you hear about us?

    Employment Work Hours
    Description of work environment
    Spouse / Significant Other’s Name: Phone #:
    Emergency Contact Name and Phone: (Other then spouse or significant other) Relationship:

    Case # Court: Judge:
    Attorney: Attorney’s Phone: FAX
    Attorney Email: Is this pre-trial / voluntary / court ordered (or a combination):
    Are you on Probation: If yes, P.O.’s Name: phone #

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