| Name: |
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| Parent or Gurdian if patient is a minor: |
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| Best time to reach you: |
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| Cell: |
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| Date of Birth: |
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| Phone: |
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| Email: |
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| Address: |
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| City: |
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| Zip Code: |
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| Insurance company: |
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| Who referred you to our office: |
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| What were you referred to our office for: |
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| Are you currently taking psychiatric medication: |
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| If yes what medications: |
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| Have you had prior counseling: |
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| If yes what was the diagnosis: |
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| How is your appetite: |
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| How is your sleep: |
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| What symptoms are you currently experiencing: |
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| What problems are you experiencing that prompted you to contact us: |
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| Do you prefer a male or female counselor: |
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| Where you referred to a specific provider: |
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