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DOMINION BEHAVIORAL HEALTHCARE Child/Adolescent Intake Forms Patient Demographics Patients Name: Appointment Date: Date of Birth: Age: Sex: Male/ Female Home Address: City: State: Zip: Home Phone:
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Parents or guardians who are submitting the form on behalf of their child or adolescent.
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What is child and adolescent new?
Child and adolescent new refers to the reporting and documentation required for children and adolescents within a specific age range.
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Parents or legal guardians are typically required to file child and adolescent new for their children.
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