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MM slash DD slash YYYY
Client Name
Date of Birth
Street Address
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Phone Type
(please note whether living in or outside of the home)

FINANCIALLY RESPONSIBLE PARTY

An adult client or an adult guardian who has assumed the cost of treatment. Payment is expected at the time of service.
Name
Address
If none reported, check here
(# of siblings, marriages/significant relationships, children, impacting events, e.g. moves, developmental changes, sexual/physical/emotional abuse, trauma, divorce.)
If none reported, check here
Abuse &/or Neglect

Medical Information

(i.e. Adhd, learning disabilities, depression alcoholism, anxiety) or neurological disorders (i.e. seizures, Tourettes, autism)
Other care professionals you are currently undergoing treatment with including a therapist doing individual counseling or others (e.g. acupuncturist, chiropractor, medical specialists, etc.)
Address
Address
Address
Address
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