Please list your children, including step, adopted and foster children
Please list your mother, father, brothers, sisters, stepfamily and/or relatives who had a significant effect upon your life (positive or negative).
If you have had any previous counseling, psychiatric treatment, substance abuse treatment, or residential/in-patient care, please list the name of the therapists and/or programs
Please include Name of Therapist/Program, Issues Addressed, and Dates in Treatment
Please list current medications you are taking even if use is seldom or as needed
Please include Name of Medication, Dosage, and Reason for taking medication
Select any of the flowing symptoms or problems that you are currently or have recently experienced
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Our broad spectrum of services include, but are not limited to: