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Name *

First Name

Last Name

DOB *

MM

DD

YYYY

Phone *

(###)

###

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What are the main issues? Check all that apply: *

Anger

Attentional difficulties

Behavioral problems

Depression

Educational difficulties

Anxiety

Autism spectrum concerns

Moodiness

Other

Check all of the following that are applicable: *

In therapy now

On psychiatric medication now

In the hospital now or recently

In therapy in the past

Taken psychiatric medication in the past

Attempted suicide in the past

Hospitalized for psychiatric reasons in the past

Known neurological or genetic disorder

None of the above

What kind of care is being sought? *

Medication

Psychotherapy

Both

Not sure