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Intake Form

Prefferd Method of Conact
Preferred method of payment per sssion
Have you ever received any type of mental health services (psychotherapy, psychiatric services, psychiatry, etc) in the past?
Are you curretly taking any prescribed mediction?
How would you rate your current physical health:
How would you rate your current sleep habits:
Have you experienced any recent changes or concern with regard to your level of actvity, apettite, or eating patterns?
Are you experiencing overwhelming sadness, grief, or depression?
Are you experiencing anxiety or panic attacks?
Are you currently experiencing any chronic pain?
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