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Get Enrollment Assessment Form

Itial: Last Name: 2. 1. Client Code: Yes No 3. Do you own or rent a house, apartment, or room? Suffix: Intake/Clinician Initials: If the answer to Q. 3 is Yes, skip to Q. 5 5. ZIP Code of Last Permanent Address: Do Not put zip code of Program. See manual for definition of Permanent. Yes No 6. Where did you stay last night? Emergency shelter 2 Transitional housing for homeless persons 3 Permanent housing for formerly homeless 4 Psychiatric hospital or o.

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