Dear Future Client, we wanted to extend our heartfelt gratitude to you for taking the time to complete our new intake form. Your willingness to share essential information about your health and needs is invaluable and greatly appreciated. Your thoroughness in providing us with this information will enable us to better understand your unique circumstances and tailor our services to meet your specific needs. Your commitment to your own well-being is a testament to your proactive approach to healthcare, and it is a pleasure to have you as a patient. Please know that your trust in our practice is not taken for granted, and we are here to support you every step of the way. If you have any questions or need further assistance, please don't hesitate to reach out. Your health and comfort are our top priorities. Once again, thank you for your time and cooperation. We look forward to working with you to provide the best possible care and support for your mental health. Warm regards, Lakeview Crew
Contact information, if applicable please provide, name, phone, and email address below:
Parents
Client's Mother
Client's Father
Others living in the household
Pregnancy/Birth
Please note the age at which of the following behaviors took place
Age for the following developments (fill in where applicable):
If yes please include all current prescribed, over the counter, supplements and/or herbal remedies used below:
Information about the child/adolescent (past & present):
By signing below, I hereby acknowledge that the information provided is true to the best of my knowledge. DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
This was signed by:
Please Attach Front and Back of Insurance Card
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