Client Information Form

B. Referral Information
Full Name

First NameLast Name
May I have your permission to thank this person for the referral?
C. You Medical Care

If doing DOT ASSESSMENTS you can leave this information blank.
Clinic/Doctor's Name

First NameLast Name
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

D. Current Employer Information
Employer Name

First NameLast Name
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Details Surrounding Your Violation:
Were you terminated from this employer? Was this a pre-employment test?
How long have you worked with this employer?
E. Education and Training

	From	To	Schools	Major	Adjustment	Graduate?
1
2

Does anyone in your family have any substance abuse disorders?

	Divorced	Domestic Partner	Married	Never Married	Separated	Single	Widowed
Marital Status

	Partner's Name	Partner's Age at Cohabitation	Your Age at Cohabitation	Your Age when separated/divorced/widowed
First
Second
Third

J. Emergency Information
Full Name

First NameLast Name
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Significant other/nearest friend or relative not living with you
This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law. Information obtained through this form WILL NOT and CANNOT BE share with any employers or Clearinghouse records.
Should be Empty:

A. Identification