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ABOUT
SERVICES
PAYMENT
JOIN THE TEAM
FORMS
CLIENT INFORMATION
CLIENT RIGHTS
CONSENT IN-PERSON SERVICES
CONSENT TO TREATMENT
FINANCIAL POLICY
PAYMENT CONTRACT
RELEASE OF INFORMATION
TELEHEALTH CONSENT
REFERRAL FOR MENTAL HEALTH SERVICES
CONTACT
Client Information
THIS SHEET MUST BE FILLED IN COMPLETELY
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Social Security Number
Today's Date
First Name
MI
Last Name
Birthday
Gender
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Street Address
Street Address Line 2
City
Region/State/Province
Postal / Zip code
Country
Country
Phone
Email
Name of Spouse/Guardian
Phone
Email
Spouse/Guardian Street Address
Spouse/Guardian Street Address Line 2
Spouse/Guardian City
Spouse/Guardian State
Spouse/Guardian Country
Country
Spouse/Guardian Zip Code
Person Responsible for Payment
Social Security Number
Signature of Person Responsible for Payment (Must be signed for services to begin)
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