Last Name

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First

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Initial

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Address

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City

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State

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Zip

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2nd Address

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City

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State

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Zip

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Home Phone

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Cell

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Alternate Phone

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Email Address

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Date of Birth

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Sex

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Marital Status

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Social Security

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Referred by

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Patient Employer

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Address

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City

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State

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Zip

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Employer Phone

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Ext

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Insurance

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Address

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City

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State

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Zip

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Phone

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Policy Holder

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Policy ID

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Group

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Relationship to patient

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Policy holders DOB

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Prior authorization

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Spouse's Name

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Work Phone

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Cell

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Nearest relative or friend not living with patient

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Relationship to the Patient

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Phone

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Cell

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Email Address

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I hereby authorize payment directly to the physician of the surgical and/or medical benefits, if any, otherwise payable to me for his/her services as described, realizing I am responsible to pay non-convered services

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I hereby authorize the physician to release any information acquired in the course of my treatment necessary to process insurance claims

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Please describe your main problem and when did it began

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What life stressors, if any, may have been related to the onset or continuation of your problem?

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What solution has been most helpful so far?

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What are your goals for treatment?

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Please describe any past emotional problems or substance abuse and treatment:

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Please describe any family history of emotional problems or substance abuse:

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List medical history, serious illness, injuries, or surgeries:

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List all medications, please include over-the-counter drugs:

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Your intake of the following: (on a daily, weekly, or monthly basis)
Alcohol

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Caffeinated Beverages

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Cigarettes

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Street Drugs

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Please check any of the following items which you may have experienced during childhood or adolescence


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What is the highest grade or degree you have achieved?

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Marital History

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Whom do you live with?

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Relationship?

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What is your present occupation?

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What type of work have you done in the past?

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Have you ever had any arrests or convictions related to substance abuse?

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