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INTAKE

Form

Please tell us about yourself

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Marital Status
Employment Status

Emergency Contact Information

(Please share details of Emergency Contact)

Medical History

Please check all that apply
Do you use tobacco?
Do you use alcohol?
Caffeine use?
Do you use Marijuana or any other Narcotic substances? (You do not need to share any details)
Are you currently taking prescription medication?
Have you had any surgeries in the past 5 years?

Mental Health History

How did you hear about us?

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