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REFERRING PARTY
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PERSPECTIVE INDIVIDUAL RECEIVING SERVICES
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Requested Service(s)
Substance Use Intensive Outpatient Services
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9 AM-11 AM
12 PM-2 PM
3 PM-5 PM
5 PM-8 PM
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PLEASE SELECT PRESENTING CONCERNS
Family Conflicts
Physical / Emotional Abuse
Sexual Abuse Victim
Low Self-Esteem
Suicidal Ideation
Depression
Anxiety
Bipolar Disorder
Substance Use Disorders
Other
Other presenting concerns
(ADHD) Adolescent
(ADHD) Adult
Academic Under-achievement
Adult-Child-Of-An-Alcoholic (ACA)
Anger
Anger Control Problems
Anti-Social Behavior
Attachment Disorder
Autism
Bed-wetting
Blended Family
Bullying / Intimidation
Childhood Trauma
Chronic Pain
Lethality to Harming Others
Dependency Issues
Disorder / Delinquency
Disruptive / Attention-Seeking
Divorce Reaction
Eating Disorders & Obesity
Enuresis / Encopresis
Fire Setting
Gambling
Gender Identity
Grief / Loss Unresolved
Impulsivity
Intellectual Development Disorder
Legal Problems
Living Environment
Lying/Manipulative
Medical Condition
Narcissistic Traits
Nicotine Abuse/Dependence
Obsessive-Compulsive Disorder (OCD)
Occupational Problems
Oppositional Defiant Behaviors
Parenting
Peer Group Negativity
Peer/Sibling Conflict
Post-Traumatic Stress
Problem Partner
Psychosis
Relational Conflicts
Self-Care Deficits- Primary
Self-Harm
Separation Anxiety
Sexual Promiscuity
Sleep Disturbance
Social Anxiety
Specific Phobia
Speech/Language Disorders
Substance Intoxication / Withdrawal
Substance-Induced Disorders
Treatment Resistance
Unipolar Depression
Other
Additional Comments
ANDORRA (+376)
UNITED ARAB EMIRATES (+971)
AFGHANISTAN (+93)
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ANGUILLA (+1264)
ALBANIA (+355)
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BURKINA FASO (+226)
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BAHRAIN (+973)
BURUNDI (+257)
BENIN (+229)
SAINT BARTHELEMY (+590)
BERMUDA (+1441)
BRUNEI DARUSSALAM (+673)
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BRAZIL (+55)
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BHUTAN (+975)
BOTSWANA (+267)
BELARUS (+375)
BELIZE (+501)
CANADA (+1)
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CENTRAL AFRICAN REPUBLIC (+236)
CONGO (+242)
SWITZERLAND (+41)
COTE D IVOIRE (+225)
COOK ISLANDS (+682)
CHILE (+56)
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CHINA (+86)
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CUBA (+53)
CAPE VERDE (+238)
CHRISTMAS ISLAND (+61)
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GERMANY (+49)
DJIBOUTI (+253)
DENMARK (+45)
DOMINICA (+1767)
DOMINICAN REPUBLIC (+1809)
ALGERIA (+213)
ECUADOR (+593)
ESTONIA (+372)
EGYPT (+20)
ERITREA (+291)
SPAIN (+34)
ETHIOPIA (+251)
FINLAND (+358)
FIJI (+679)
FALKLAND ISLANDS (MALVINAS) (+500)
MICRONESIA,FEDERATED STATES OF (+691)
FAROE ISLANDS (+298)
FRANCE (+33)
GABON (+241)
UNITED KINGDOM (+44)
GRENADA (+1473)
GEORGIA (+995)
GHANA (+233)
GIBRALTAR (+350)
GREENLAND (+299)
GAMBIA (+220)
GUINEA (+224)
EQUATORIAL GUINEA (+240)
GREECE (+30)
GUERNSEY (+44)
GUATEMALA (+502)
GUAM (+1671)
GUINEA-BISSAU (+245)
GUYANA (+592)
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HONDURAS (+504)
CROATIA (+385)
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HUNGARY (+36)
INDONESIA (+62)
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ISRAEL (+972)
ISLE OF MAN (+44)
INDIA (+91)
IRAQ (+964)
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ICELAND (+354)
ITALY (+39)
JAMAICA (+1876)
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JAPAN (+81)
JERSEY (+44)
KENYA (+254)
KYRGYZSTAN (+996)
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KOREA DEMOCRATIC PEOPLES REPUBLIC OF (+850)
KOREA REPUBLIC OF (+82)
KUWAIT (+965)
CAYMAN ISLANDS (+1345)
KAZAKSTAN (+7)
LAO PEOPLES DEMOCRATIC REPUBLIC (+856)
LEBANON (+961)
SAINT LUCIA (+1758)
LIECHTENSTEIN (+423)
SRI LANKA (+94)
LIBERIA (+231)
LESOTHO (+266)
LITHUANIA (+370)
LUXEMBOURG (+352)
LATVIA (+371)
LIBYAN ARAB JAMAHIRIYA (+218)
MOROCCO (+212)
MONACO (+377)
MOLDOVA,REPUBLIC OF (+373)
MONTENEGRO (+382)
SAINT MARTIN (+1599)
MADAGASCAR (+261)
MARSHALL ISLANDS (+692)
MACEDONIA,THE FORMER YUGOSLAV REPUBLIC OF (+389)
MALI (+223)
MYANMAR (+95)
MONGOLIA (+976)
MACAU (+853)
NORTHERN MARIANA ISLANDS (+1670)
MAURITANIA (+222)
MONTSERRAT (+1664)
MALTA (+356)
MAURITIUS (+230)
MALDIVES (+960)
MALAWI (+265)
MEXICO (+52)
MALAYSIA (+60)
MOZAMBIQUE (+258)
NAMIBIA (+264)
NEW CALEDONIA (+687)
NIGER (+227)
NIGERIA (+234)
NICARAGUA (+505)
NETHERLANDS (+31)
NORWAY (+47)
NEPAL (+977)
NAURU (+674)
NIUE (+683)
NEW ZEALAND (+64)
OMAN (+968)
PANAMA (+507)
PERU (+51)
FRENCH POLYNESIA (+689)
PAPUA NEW GUINEA (+675)
PHILIPPINES (+63)
PAKISTAN (+92)
POLAND (+48)
SAINT PIERRE AND MIQUELON (+508)
PITCAIRN (+870)
PUERTO RICO (+1)
PORTUGAL (+351)
PALAU (+680)
PARAGUAY (+595)
QATAR (+974)
ROMANIA (+40)
SERBIA (+381)
RUSSIAN FEDERATION (+7)
RWANDA (+250)
SAUDI ARABIA (+966)
SOLOMON ISLANDS (+677)
SEYCHELLES (+248)
SUDAN (+249)
SWEDEN (+46)
SINGAPORE (+65)
SAINT HELENA (+290)
SLOVENIA (+386)
SLOVAKIA (+421)
SIERRA LEONE (+232)
SAN MARINO (+378)
SENEGAL (+221)
SOMALIA (+252)
SURINAME (+597)
SAO TOME AND PRINCIPE (+239)
EL SALVADOR (+503)
SYRIAN ARAB REPUBLIC (+963)
SWAZILAND (+268)
TURKS AND CAICOS ISLANDS (+1649)
CHAD (+235)
TOGO (+228)
THAILAND (+66)
TAJIKISTAN (+992)
TOKELAU (+690)
TIMOR-LESTE (+670)
TURKMENISTAN (+993)
TUNISIA (+216)
TONGA (+676)
TURKEY (+90)
TRINIDAD AND TOBAGO (+1868)
TUVALU (+688)
TAIWAN,PROVINCE OF CHINA (+886)
TANZANIA,UNITED REPUBLIC OF (+255)
UKRAINE (+380)
UGANDA (+256)
UNITED STATES (+1)
URUGUAY (+598)
UZBEKISTAN (+998)
HOLY SEE (VATICAN CITY STATE) (+39)
SAINT VINCENT AND THE GRENADINES (+1784)
VENEZUELA (+58)
VIRGIN ISLANDS,BRITISH (+1284)
VIRGIN ISLANDS,U.S. (+1340)
VIET NAM (+84)
VANUATU (+678)
WALLIS AND FUTUNA (+681)
SAMOA (+685)
KOSOVO (+381)
YEMEN (+967)
MAYOTTE (+262)
SOUTH AFRICA (+27)
ZAMBIA (+260)
ZIMBABWE (+263)
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