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Primary Cardholder's Name
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Primary Cardholder's DOB
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Why are you seeking therapy at this time?
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How were you referred to our office?
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Are you currently or have you ever experienced suicidal ideations or have been previously hospitalized for psychiatric reasons?
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Please indicate any medications you have been previously prescribed and/or currently taking.
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Is there any ACS involvement?
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Is there any history of substance use?
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2281 Victory Blvd - Westerleigh
3710 Richmond Ave - Eltingville
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