Bayside Therapy Associates Adult Intake Form (Page 4 of 4) in pdf

Bayside Therapy Associates Adult Intake Form Page 4

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SOCIAL-ECONOMIC HISTORY: (Continued): (check all that apply for client

Military History:

Social Support System:

Education:

Never in Military

Supportive Network

Did Not Complete

Served in Military – No

Few Friends

High School

Combat

No Friends

Completed High School

Served in Military –With

Distant From Family of

GED

Combat

Origin

Years of College _______

College Degree: ________

Cultural/Spiritual (e.g., ethnicity, religion): ___________________________________________________

List persons living in clients home:

Name

Age

Relationship to client

List children not living in the home:

Name

Age

Relationship to client

TREATMENT GOALS:

Please list issues to discuss in therapy and specific goals you wish to accomplish:

______________________________________________________________________________________________________

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Bayside Therapy Associates Adult Intake Form Page 4