Recovery Support Services & Case Management Recovery Support Services and Case Management Recovery Support Services and Case Management Demographic Information CITC Client ID # (if known): This is not the RSCMS ID#. If you do not know the CITC Client ID #, then leave this section blank. Did a CITC staff person assist you with filling this out? If so, please put the staff person's name here: First Name * Middle Initial (if you don't have a middle initial, please enter 0) * Last Name * Street Address * City * State * Zip * What is your cell phone number? * What is your email address? * What is your Date of Birth? * Are you currently receiving treatment services? * Yes No If "Yes", when are you expected to graduate? Are you interested in receiving Case Management or Recovery Coach Services? * Yes No Are you a beneficiary at the Alaska Native Medical Center or Indian Health Services (IHS)? * Yes No **for funding purposes. Some funds come from Indian Health Services (IHS). Are you receiving services or have you ever received any services from any other CITC Department? If so, which department(s)? Alaska's People Employment and Training Family Services Education Youth Services Do you have children living at home? * Yes No If you are human, leave this field blank. Next
