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Client Information
Hi, please fill out the following details. While I may already have some of your information, this form will help me organize it more effectively. All information provided will be strictly confidential, and will only be available to your therapist, Nikhil Vinodh.
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Name
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Email
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Address
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Phone number
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Birthdate
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YYYY
Age
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Your answer
Race/Ethnicity
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Gender Identity
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Sexual Orientation
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Employment Status
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Employer (if any)
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Primary Physician Name
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Primary Physician Contact Number
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Psychiatrist Name
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Psychiatrist Phone Number
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Please list any medications that you take, including dosage and frequency
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Please list any health conditions that I should be aware of
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Emergency Contact name and relationship to you
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Emergency Contact phone number
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