Patient Information
Welcome to the practice!  Please complete this form to the best of your ability. If you are a parent/guardian, please include information pertaining to the identified patient.
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Patient Full Name *
Patient Date of Birth *
MM
/
DD
/
YYYY
Address *
Home Phone Number
Cell Phone Number
Work Phone Number
Email Address
Parent/Guardian names and contact information, If patient is under 18.
Relationship Status
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What is your occupation/employment status?
Please list the names and titles of previous mental health treatment providers (including hospitals and/or crisis units).  Additionally, please indicate when you were last seen by each.
Are you currently on any medication? (If yes, list in other) *
Have you ever been diagnosed with or experienced symptoms related to any of the following (check all that apply)
Do you have any medical issues or complaints?
What are your pronouns? (check all that apply)
When are the best times for you to meet?
What type of counseling are you seeking?
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Please share a little bit about why you are seeking support at this time (this can include general information, current symptoms, goals, etc.). 
Is there anything you'd like me to know before we get started? 
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