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INTAKE ASSESSMENT/NETMIS Family Action NonResidential Program CDS CONFIDENTIAL 4. YOUTH INFORMATION: Netmis ID: Religious Affiliation:Full Name: Place of Birth: Alias/ Preferred/ Nickname: Date of Birth:Home Address: (street) ___(city)___ (state)___ (zip)___ (county)___(phone #)___ (cell #)___ Education Information: School Name:Special Education Classes: yes___ no___ Current Grade: ___School Address: (street) ___(city)___ (state)___ (zip)___ (county)___(phone #)___ (fax
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