Please complete if you are utilizing insurance. If possible, please attach a copy of both sides of your ID card.
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The following initial information gathering is completely confidential. You will not be judged by your answers, nor expected to maintain the status quo. Any question left blank will be reviewed in session. You are not required to answer all questions. Please be reminded that any private information that you will prefer not written down and that is not of a criminal or threatening nature, will be held in strict client confidence.
Thank you for sharing this information. It will be held in confidence.
Before Submitting, review the form for missing or required information.