Stacey S Intake

INTAKE ASSESSMENT

Patient:
Date of Birth:
Intake Date:
Reason for Seeking Therapy:   	

Presenting Symptoms: 
[textarea name="variable_1" default="sample text"]   	
Presenting Problem History: 
[textarea name="variable_1" default="sample text"]   	
Family History: 
[textarea name="variable_1" default="sample text"]   	
Education and Occupational History: 
[textarea name="variable_1" default="sample text"]    	
Medical Problems: 
[textarea name="variable_1" default="sample text"]   	
Current Prescription Medications: 
[textarea name="variable_1" default="sample text"]
Alcohol, Nicotine, and Drug History: 
[textarea name="variable_1" default="sample text"]  	
Mental Health Treatment History: 
[textarea name="variable_1" default="sample text"] 
Legal History: 
[textarea name="variable_1" default="sample text"]  	
Spiritual Life: 
[textarea name="variable_1" default="sample text"]
INTAKE ASSESSMENT

Patient:
Date of Birth:
Intake Date:
Reason for Seeking Therapy:

Presenting Symptoms:

Presenting Problem History:

Family History:

Education and Occupational History:

Medical Problems:

Current Prescription Medications:

Alcohol, Nicotine, and Drug History:

Mental Health Treatment History:

Legal History:

Spiritual Life:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0, 10 form elements, 41 boilerplate words, 10 text areas, 10 total clicks
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