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Please upload divorce decree or child custody paperwork

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Social history

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Family history

Tell us about any history of mental illness in your parent(s), grandparent(s), sibling(s) and relatives.

Illness Father Mother Aunt Uncle Brother Sister Children Children
heart disease
substance abuse
suicide attempts

List and describe any past hospitalization(s)

How frequency do you consume alcohol?

Weekly consumption. (i.e. 2 times a week)

How frequency do you smoke?

Weekly consumption. (i.e. 2 times a week)

Are you currently pregnant or is there a change you could be?

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Are you requesting this appointment for any legal issues such as child custody, disability, job clearances, or workman's comp related matters?

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