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Please print the informed consent document and bring it with you to your first appointment.

Also, please fill out the following information:

Name *

First

Last

Email *

Date of Birth

Phone

Address

Marital Status

Primary Physician

Medication Allergies

Pre-Diagnosed Conditions

Does anyone in your family have a history of alcohol or drug abuse?

Do you currently drink alcohol and how much?

Do you currently use drugs?

Emergency Contact

Why are you seeking therapy?

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