• ABHS INTAKE DATA FORM

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  • 1. Personal Identification Information

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  • 2. Parent/Legal Guardian Information

  • Please complete this section only if you are under the age of 18 years.

  • 3. Spouse/Partner

  • Please complete this section only if you are married or in a committed relationship.

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  • 4. Insurance Information

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  • 5. Family Data

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  • 6. Health Information

  • If you give us permission to contact your Primary Care Physician to coordinate care, please sign your name and date below:

  • Clear
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  • If you give us permission to contact your Psychiatrist or Psychiatric NP to coordinate care, please sign your name and date below:

  • Clear
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  • (6—Health Information, Continued)

  • 7. Treatment History

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  • 8. Problem Checklist

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  • 9. Degree of Distress/Disruption, & Treatment Expectations

  • 10. Strengths, Supports, Leisure

  • Should be Empty:
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