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DATE PATIENT NAME DOB PATIENT CONTACT: Home: Cell: PHYSICIAN NAME PHYSICIAN CONTACT: Phone: Fax: REFERRAL SOURCE (if other than physician) REFERRAL CONTACT: Phone: Fax: PRESENTING PROBLEM for Counselling/Psychological
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Individual adult childadolescent couples refer to a group consisting of one individual adult, one child, and one adolescent who are all related.
Individual adult childadolescent couples may be required to be filed by social workers, psychologists, or therapists who work with families.
To fill out individual adult childadolescent couples, gather information about the adult, child, and adolescent, and their relationships and dynamics.
The purpose of individual adult childadolescent couples is to understand the dynamics and relationships among members of a family unit.
Information such as age, gender, relationship dynamics, and any issues or challenges within the family must be reported on individual adult childadolescent couples.
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