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Introduction

Birthdate
Month
Day
Year
Today's Date
Month
Day
Year
Marital Status
Preferred Contact Method
Select Payment Type

Co Pay / Session Fee is due at the BEGINNING of EACH APPOINTMENT.

Payment can be Cash, Check, or Credit Card and will be made to the Therapist or Office Manager Directly

WE DO NOT MAKE REMINDER CALLS BEFORE APPOINTMENTS

Adult Information Form

Fill in all applicable fields

Please check all behaviors/symptoms that you consider problematic
Are your problems affecting any of the following
Have you ever had thoughts, made statements, or attempted to hurt yourself? (Yes or No)
Yes
No
Have you ever had thoughts, made statements, or attempted to hurt someone else? (Yes or No)
Yes
No
Have you recently been physically hurt or threatened by someone else? (Yes or No)
Yes
No

Please Submit and then open the Family Relationship Form

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