MILITARY

Please Check All that apply below.

Current Legal Status, Restrictions, or Requirements: (documentation must be on file):

FAMILY/HOME INFORMATION:

List others living in the home: (If more than two please place on back)

PRIMARY CARE/MEDICAL

Please list Medications Below(If more than 5, please list in additional box):

Medicine /  Dose  /  Frequency /  Who Prescribes

If suicidal, homicidal, gravely impaired, presenting with urgent or critical needs further clinical guidance, contact a licensed clinician to further assess for triage! Document clinical disposition when applicable.