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New Client Intake Form Version 3. 0 303 E. Court St. Atoka Ok 74525 580 889-3399 FAX 580 889-3887 Intake and Assessment Checklist LXE Pamphlet Consumer Handbook Registration Page Termination of Service Consent for Treatment Consent for Release of Confidential Information Insurance Authorization Consent for Follow Up Bio-Psychosocial Assessment Immunization under age 14 only Provide Client with Copy of Contract Client/Guardian Clinician Signature Page 1 Request for Services Name DOB Maiden...
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