General Information Forn

Page 3

Please check yes or ao for each of the following health services

not they are available in a clinic serving area?
the service, its availability, and reliabilicy.
Type of Health Service

No

Optical services

CIC]

Medicines or pharmacy
services

14.

Rehabilitation service

a

bs

‘
+
a
—

Care for the ages

16.

Psychiatry services

17.

Suicide prevenrion services

18.

Alcohol rehabilitation

19.

Alcoholism preventicn

20

Drug abuse rehabilitation
Drug abuse prevention
STD services
Other health services

Yes

s to whether or
If you check ye » Please describe

Nature of Service, Avadlability, Reliabilir

Select target paragraph3