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Substance Abuse Screening Assessment
Confidential • Free • Takes 5-10 minutes
Personal Information
Full Name / Amazina *
Age / Imyaka *
Gender / Igitsina *
Select
Male / Gabo
Female / Gore
Other / Ikindi
Marital Status / Arubatse cg Ingaragu
Select
Single / Ingaragu
Married / Arubatse
Divorced / Batandukanye
Widowed / Bapfakazi
Education Level / Amashuri wize
Select
No Formal Education / Nta mashuri yize
Primary / Abanza
Secondary / Ayisumbuye
High School / Icyiciro cya kabiri
Vocational/Technical / Umwuga/Tekiniki
University / Kaminuza
Postgraduate / Impamyabumenyi y'ikirenga
Religion / Imyemerere
Phone Number / Tel *
Next of Kin's Phone / Tel. y'umuntu ukwitaho
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