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INTAKE FORM
Name
Phone
Stressors (Please mark an (X) if you have problems in the following areas and explain on the back
Family
Friends
Relationships
Economic
Housing
Lack of Exercise
Lack of social Activity
Health
Sleep
Nutrition
Legal
Smoking
Substance Abuse
Other
Email
Address
Age
Birthday
SSN
Marital Status:
Single
Married
Divorced
Widowed
Seperated
Authorized Representative/Legal Guardian’s Home/Street Address
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