Midwest Tribal Case Presentation Form 2021

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* 1. Your name

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* 2. Your clinic name

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* 3. Patient Demographics

Age

Gender Identity

Housing Status

Relationship Status

Employment Status

For substance use questions, please indicate substance, route, frequency, and duration

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* 4. Current substance use:

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* 5. Past substance use:

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* 6. MAT history:

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* 7. Mental health conditions

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* 8. Chronic health conditions

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* 9. Legal/CPS involvements

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* 10. Social supports/barriers

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* 11. Other relevant information

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* 12. Please state your KEY QUESTION/COMMENT