Minor Patient

Intake Assessment

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Your name
Child's Name
Please provide the full home address(es) at which the child is currently living.
Biological Father's Name
Biological Mother's Name
Custodial Father's Name
Custodial Mother's Name
Does the father primarily work outside of the home?
Does the mother primarily work outside of the home?
Please list each method and frequency of use
Please select any symptoms from the below list that the child has displayed
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