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Name
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First
Last
Date Of Birth
Phone number
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Please insert Copy of Insurance (front and back)
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Do you have secondary insurance?
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Insurance Name
Insurance ID
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What is the reason for the visit?
Is that your 1st therapy appointment?
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Do you take any psychiatry medications ?
YES
NO
Is your visit is related to any Form or paper work to be done by the provider?
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NO
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