Individual Therapy

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For Clients under 18 years of age

Employement Information

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Academic Information

How you found this clinic

How you found this clinic
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Psychiatric and Medical History

Mental Health Treatment History

Have you ever been hospitalized for psychological or psychiatric reasons?

Current Habits

Please describe your current habits in each of the following areas:
Smoking
Gambling
Drinking
Drug Use
Caffeine Intake
Exercise
Eating
Sleeping
Fun & Relaxation

Relationships

Please describe your relationships with each of the following people, if applicable

Stressful Life Events

Please describe any current significant or stressful life events that you have been experiencing

No Yes If yes, please describe
Economic problems?
Difficulty accessing health care?
Legal issues or crime?
Cultural issues?
Family conflict or lack of support?
Social problems?
Educational or occupational
difficulties?
Housing problems?
Grief or bereavement?
Other?
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