The Altamont Program TLC

575 Broadway, Menands, NY 12204
(518) 463-1121; fax (518) 463-0826

Directions: print out this page and fill out all information with your institutional officer, then mail or fax to the above address.

Name

Date of Birth

Social Security #

DOC Facility

Proj. Release Date

Post-Release Parole Office Assignment:

Post-Release Residential Plan:

Post-Release Source of Financial Support:

Post-Release Treatment Plan:

Mental Status Evaluation Report (DSM-III R Multi-Axial)

AXIS I

AXIS II

AXIS III

AXIS IV

AXIS V

Alcohol And Drug Abuse History (include factors that led to abuse, relapse indicators, treatment programs, longest period of sobriety, last date of abuse):

Post-Release Occupation Plans:

Recommended Post-Release Treatment Plan:

Please attach psychiatric and medical reports

Signature

Print Name

Title

Date

Phone #