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Record of Service(s) Rendered

Use this short form every time OHPM provides Resources, Services or Referrals to a client after their initial visit and between their 30 and 90 day follow-ups.

How can we help?

1. Has your client been incarcerated previously?
Yes
No

Client Contact

Gender
Male
Female

Services Offered/Provided today

Date and time
Month
Day
Year
Time
HoursMinutes
These advanced services may also be offered at a future visit. Kindly review these with your client.
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