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Group Therapy Intake Form

Telehealth only

Date of Birth
Sex ( for insurance purpose only)
Address Type
Are you Insured?
Following Insurances
Are you in individual therapy currently?
Yes
No

Mental Health Diagnoses 

Have you ever been diagnosed with any mental health disorders?
Yes
No
Current or Past Mental Health Providers?
Yes
No

Current Medications? 

POLICY HOLDER

Date of Birth

IF YOU ARE NOT THE SUBSCRIBER OF THE INSURANCE POLICY PLEASE ENTER THE SUBSCRIBERS INFROMATION

Insurance Type
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