Tropical Leaves

Referrals

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Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

Referral Information

Client Information

Gender

Parent or Legal Guardian Information

Please answer the following:

Is the consumer of Hispanic, Latino, or Spanish Origin?
Race
How Well Does the Consumer Speak English?
Does the Consumer Speak Another Language at Home Besides English?

History

Cigarette Use
Military Experience
Primary Source of Income
Registered Sex Offender
Length of Current Use:
Method of Use
Length of Current Use:
Method of Use

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Background
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Referral for Substance Use Disorder

Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

Referral Information

Client Information

Gender

Parent or Legal Guardian Information

Please answer the following:

Is the consumer of Hispanic, Latino, or Spanish Origin?
Race
How Well Does the Consumer Speak English?
Does the Consumer Speak Another Language at Home Besides English?

History

Cigarette Use
Military Experience
Primary Source of Income
Registered Sex Offender
Length of Current Use:
Method of Use
Length of Current Use:
Method of Use
Length of Current Use:
Method of Use
Areas of Supportive Need (Check all that apply):

Thanks for submitting!