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What is the reason for seeking care?

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What kind of care is being sought?

Psychotherapy Other

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Attempted suicide in the past None of these apply

Current Therapy Needs and Goals

What kind of therapy are you seeking, how often and what goals do you hope to achieve in treatment?

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