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Intake Form
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Date (dd/mm/yyyy)
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Name
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First
Last
Gender
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Male
Female
Other
Age
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Date of Birth(dd/mm/yyyy)
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Email
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Phone Number
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Can I leave a voicemail?
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Yes
No
Address
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Line 1
Line 2
City
State
Zip Code
Country
How did you primarily know about Bahar Partou's psychotherapy services?
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Finding this website directly on google
Through Bahar Partou's Facebook page
Finding this website on "Psychology Today" website
Through Better Life Counselling Center website
Through "Mard-e-Rooz" magazine
By my family physician
By another practitioner
By another Client
Word of mouth
Other
Name of the referral source if applicable
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Relationship Status
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Single
In a relationship
Engaged
Married
Divorced
Widow
Other
If you have children, please mention their age and sex
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Employment Status
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Unemployed
Part time job
Full time job
Self-employed
Other
Job Title/Position
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Education Level and Major
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Counselling experience?
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Yes
No
If yes, please mention the reason briefly
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Have you ever recieved clinical diagnosis for any psychological disorders?
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Yes
No
If yes, please select all that applies
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Depression
Bipolar
Generalized Anxiety Disorder (GAD)
Social Anxiety/Phobia
Panic
Specific Phobias
Obssesive Compulsiva Disorder (OCD)
Schitzophernia
Post Trumatic Stress Disorder (PTSD)
Personality Disorder(s)
Other
Have you ever used pschiatric medications?
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Yes
No
If yes, please name as much as you remember
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Do you have or have you ever had serious suicidal thoughts or actual suicidal attempts?
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Yes
No
If yes, please briefly explain
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Do you suffer from any kinds of chronic illness?
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Yes
No
If yes, please name
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Emergency contact (name)
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His/her relationship with you
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His/her phone number
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Anything else you want me to know about you?
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