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Adult Intake Form

The information you provide on this intake form is STRICTLY CONFIDENTIAL.

In order to contact you and to arrange a consultation and for future contact, please confirm the means by which we are allowed to contact you.
Please provide an insight why you have chosen to seek therapy at this time.
Stress, anger, sleep problems, impotence, headaches, sexual disfunction, ocd, bad habits.
Depression, anxiety, bipolar, heart condition, cancer, asthma, diabetes.