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Please complete the following. When complete his done and it will send over your responses. 

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* 1. Full Name

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* 2. Email Address

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* 3. Full SSN

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* 4. Date of Birth

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* 5. If you have been hospitalized for mental health, what were the reasons?

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* 6. How old were you when you first used and tell us about the progression? (Example: Age/Substance)

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* 7. Is opiates/fentanyl your primary drug of use?

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* 8. When did you last use? 

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* 9. Route of delivery for opiates/fentanyl?

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* 10. Are there other substances that you are using?

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* 11. If yes, what other substances are you using?

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* 12. Do you have any health conditions that you want to share with us?

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* 13. Do you have a history of assaultive or violent behavior towards other people?

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* 14. If yes, explain

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* 15. Do you have current thoughts of violence towards other people? 

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* 16. If yes, explain

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* 17. Do you have a history of self-harm?

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* 18. If yes, explain

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* 19. In the past few weeks, have you wish that you were dead? 

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* 20. If yes, please explain

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* 21. In the past few weeks, have you believe that your friends or family would be better off if you were dead?

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* 22. If yes, please explain

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* 23. In the past few weeks, have you thought about killings yourself?

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* 24. Do you currently have a plan to kill yourself?

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