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Menu
Home
Services
About Us
Our Team
FAQ
Contact Us
Book an Appointment
ACE Release of Records
Encounter Form
Patient Bill of Rights
Consent for Outpatient Behavioral Health
HIPAA Notice of Privacy
Client Information
Client and Family Responsibilities
Make A Payment
(610)796-8110
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Records
Client Information
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Client Information
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Name
*
DOB:
*
MM slash DD slash YYYY
SSN#:
*
Age:
*
Please enter a number greater than or equal to
1
.
Gender:
*
Male
Female
Address:
*
Street Address
Phone #:
*
Alternate Ph #:
*
Email address:
*
Names of Legal Guardians:
*
Guardian Ph#:
*
Referral Source-Name/Ph #:
*
Emergency Contact- Name/ Ph#:
*
Name of Primary Care Physician/Ph#:
*
Name of School/ Ph#:
*
Primary Insurance:
*
Insurance ID:
*
Secondary Insurance
*
Insurance ID:
*
Do you have an Advanced Directive?
Yes
No
Presenting problems (Check all that apply):
Depression
Anxiety
Trauma
Grief/Loss
Psychosis
OCD Symptoms
Oppositional behaviors
Attention/hyperactivity
Sleep Disturbance
Developmental delays
Anger management
Other:
Other:
*
List all known allergies and adverse reactions:
*
Do you have a Wellness Recovery Action Plan (WRAP Plan)?
Yes
No
Special Accommodations (if any):
Signature of Client/ Legal Guardian
*
Date
*
MM slash DD slash YYYY
Comments
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