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2. First Name*
3. Last Name*
5. Date*
   Date
6. Phase*
   -- Select One --12345
10. Date/Time Leaving*
    Date/Time Leaving

    Date/Time Leaving
11. Date/Time Returning*
    Date/Time Returning

    Date/Time Returning
13. Special Request/Reason*

    What is your request? Be specific.

15. How will you get there?*
17. Name, relationship, and address of who you are traveling with and where you will be*
21. Explain how will this benefit your treatment, long term sobriety, and/or case/treatment plans*
23. Are you going to miss treatment (individual and/or group)?*

    1. Yes

    1. No
24. If YES, list dates of missed treatment:
26. Are you going to miss a check in?*

    1. Yes

    1. No
27. If YES, list dates of missed check in:
29. Are you going out of state?

    1. Yes
    2. No
30. If YES, did you submit your travel request to DOC?

    1. Yes
    2. No
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field