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  • Symptoms and goals check-in

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  • Please check the box next to the number that best describes your experience

    Over the last 2 weeks, on how many days have

    you been bothered by any of the following

  • By signing below, you are verifying that you are the individual that completed this document. You also agree for Mantra Mental Health, LLC to bill any new insurances provided. You also agree that your therapist may contact your emergency contact in the case of an emergency.

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