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Salt Lake County Division of Substance Abuse Services REFERRAL FOR MEDICATION EVALUATION Name of Referring Agency Full Address of Agency Client s Full Name MIS Number Client s Social Security Number Date of Birth Client s Last Known Address County State Client s Funding Code ASAM Level Date Client Entered Treatment Date of Last Use of Alcohol and/or Drugs Presenting problem and reason for referral Please list all medications the client currently is taking including over the counter meds...

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