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Patient Intake Form

Bravery is not the absence of fear. Bravery is feeling the fear, the doubt,
the insecurity, and deciding something else is more important

– Mark Manson

1 Step 1
Patient Intake Form
Children
Please list name, age, and any other information pertinent
Please provide a list of therapists/coaches you have seen within the last (3) years. For each, include whether Trident Healing has permission to contact him or her on your behalf.
Current?
Allowed to Contact?
Current?
Allowed to Contact?
Current?
Allowed to Contact?
Please list current healing groups you are involved with (ex. AA, SLAA) and how often you attend.
Anxiety
Anger
Depression
Alcohol Use
Substance Abuse
Gambling
Workalholism
Food Addiction
Health Issues
Feelings around Family Tree Please share adjective/feeling for each family member
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