Oregon > Local County > Malheur > Circuit Court > Drug Court
Client Information - Oregon
| Client Information Form. This is a Oregon form and can be used in Drug Court Circuit Court Malheur Local County . |
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MALHEUR COUNTY CIRCUIT COURT S.A.F.E. COURT PROGRAM Malheur County Courthouse 251 B Street West - Vale, OR 97918 541/473-5533 CLIENT INF ORMATION Name:__________________________ Case Number:_________________Date:____________ Address:_________________________________ City:____________ State:_____ Zip:______ Phone #:_________________ SSI#:___________________Race:___________ DOB:_________ Emergency Contact Person: Phone: Relationship: Gender: __Female __Male Expecting a child? No:____ Yes: Due date: Children and their ages: Marital Status: ____Single ____Married ____Separated____Divorced ____Living as Married Highest Grade Completed GED College Current Student/where?: Do you wish to return to school? Monthly Income:________ Gross monthly household income:__________ Source:___________ Employed: ___Yes ___ No If unemployed, list job skills: Receiving Unemployment Benefits? Name of Employer:___________________ Position:__________Length of Employment:______ Address of Employer:_____________________________ City:______________ State:______ Employers Phone Number:____________________ Supervisors Name: Medical Insurance:______________________ Number: Physician Name:_________________________________ Present Prescribed Medications: Drug(s) of choice: Number of arrests in the last 5 years:_______ Current Charges:___________________________ Is your license suspended as a result of Driving Under the Influence? __ Yes __ No If yes, What County:______________ City:__________________State____________________ (12/7/01)
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