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Annette Fiedler Counseling & Associates
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Pre-Trial Release / Probation Screening
Name:
Date:
Address
Phone that you can be contacted:
Date of Birth:
Pre Trial Release/Probation Officers Name:
Email that you check regularly:
Do you take medication daily? Please list dosage & reason:
Consent for Treatment:
Payment Policy
Additional Information:
Consent for Direct Specimen Observation:
I agree and acknowledge ALL the terms of the Pre-Trial Release/Probation agreement above.
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Credit Card Authorization Form.
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