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Date of Birth
City, State, Zip
Father's name if client is a minor
Father's DOB if client is a minor
Mother's name if client is a minor
Mother's DOB is client is a minor
Has the client been in psychoterapeutic or psychiatric care?
If so, please provide the therapist's/doctor's name(s)
Primary Care Physician
Is the client covered by insurance?
If so, please provide the insurance company:
Insurance Group Number
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