Please provide the following information for our records. Leave blank any question you would rather not answer, or would prefer to discuss with your therapist. Information you provide here is held to the same standards of confidentiality as our therapy.
Has anyone in your family (either immediate family members or relatives) experienced difficulties with the following? (circle any that apply and list family member, e.g. sibling parent, uncle, etc.)
All information provided herein will be treated by StreSERT with utmost confidentiality. Duplication of this information for further disclosure is prohibited without prior written authorization of the client/ authorized representative to whom it pertains unless other permitted by law.
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