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INTAKE FORM FOR PARENT AND CHILD This intake form requires information on BOTH parent and child. Please read each section carefully to understand which section pertains to you and which selection pertains to your child. PARENT INFORMATION First Name MI Last Name Address City State Zip Date Home PH Work PH DOB / / Male Female SSN - - CUSTODIAL PARENT INFORMATION Who has legal custody of this child Same as above if checked no need to complete the rest of this box Insurance Company Information...

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