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Passion. inspiration. nourishment. Clinical Counselling/Psycho-Nutra Therapy Intake Form Client Name Date Date of Birth Gender Phone 1 Address Email Family Members living in the household Name Age Relationship to Client Family Structure single couple single with children common law married grandparents etc. History of Mental Health Issues History of Trauma History of Substance Abuse No History/Personal History/Parents/Current Partner Doctors Choice Naturopathic Clinic 1190 Thurlow Street...
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