Integrative Counseling Solutions, Inc.
Possibilities Program
Name
First Name
Last Name
Sex
Male
Female
Month
Day
Date of Birth
/
Month
/
Day
Year
Date
Last 4 numbers of Social Security number
Ethnicity
Not Spanish/Hispanic/Lating
Cuban
Puerto Rican
Other Hispanic or Latino
Mexican
Unknown
Race
Black/African American
Hawaii or Pacific Islander
American Indian
Alaska Native
Asian
Unknown
Phone Number
Phone Number
Please enter a valid phone number.
Home Address
Number
Street
City
County of Residence
IV Drug Use in last 30 days
Yes
No
Is this intake/assessment a result of a legal issue
Yes
No
Insurance Provider
Group #
ID#
Policy Holder
DOB
Policy Holder's Employer
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