This government document is issued by Drug and Alcohol Programs for use in Pennsylvania
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https://www.google.com/url?client=internal-element-cse&cx=007572080359491747877:ug3qpcrqbm4&q=https://www.ddap.pa.gov/Documents/Agency%2520Forms/SCA%2520Prevention%2520Program%2520Request%2520Form.pdf&sa=U&ved=2ahUKEwjhz9bhlPGFAxUxiP0HHRGND6oQFnoECAUQAQ&usg=AOvVaw0g2e5MEMbijX2BvJhVXxxA