HEALTH AND SOCIAL INFORMATION

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Have you ever experienced any of the following?

OCCUPATIONAL INFORMATION

EDUCATIONAL INFORMATION

RELIGIOUS/SPIRITUAL INFORMATION

MARITAL INFORMATION

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FAMILY COMPOSITION

OTHER INFORMATION

Consent For Communication
No Show, Late Cancellation and Co-payment Policy
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Health Insurance Claim Form

Primary Insurance Information:

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Person policy is under*
Person policy is under*
Person policy is under*

SECONDARY Insurance Plan (If not applicable, skip)

Person policy is under*
Person policy is under*
Person policy is under*
Patient’s or Authorized Person’s Signature: I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment claims related to medial services provided.
INFORMED CONSENT TO INDIVIDUAL PSYCHOTHERAPY
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