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Radish Person, MA, LEFT 518 East Main St., Santa Maria, CA 93454 805-346-1999 phone 805-346-1998 fax INTAKE FORM FOR PSYCHOTHERAPEUTIC SERVICES Identifying Information Name: Sex: Birth date: Age:

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How to fill out intskr packet o 346:

1. Begin by gathering all the necessary information and documentation required to complete the packet.
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3. Start with the first section of the packet and provide the requested personal information accurately and completely.
4. Move on to the next section and carefully fill in any additional details or specific information required for the application.
5. Review each section of the packet to ensure all required fields have been properly filled out.
6. Attach any supporting documentation that may be required, such as identification proof, certificates, or other relevant papers.
7. Double-check the packet to ensure all sections have been completed, all information is accurate, and all necessary documents have been included.
8. Sign and date the packet as instructed, certifying the information provided is true and accurate.
9. Pay attention to any additional submission requirements, such as mailing the packet to a specific address or submitting it online.
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