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LIZA C. MERMELSTEIN, Behavior THERAPY ASSOCIATES, LLC9426 Indian School Road NE, Suite #1Albuquerque, NM 871125053456100NEW PATIENT INFORMATION: CHILD AND ADOLESCENT FORMTodays Date: Name: DOB: /
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01
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Start by filling out the personal information section of the form, which includes the name, date of birth, and contact details of the child or adolescent.
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Fill out the section related to the child's or adolescent's current medications, if applicable.
05
Provide information about the child's or adolescent's immunization status, including the dates of vaccinations received.
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Complete any additional sections or questions that may be present, such as family medical history or psychological evaluation.
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Parents or legal guardians of children and adolescents who are seeking healthcare services or enrolling them in a new healthcare facility.
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Child and adolescent new refers to a specific framework or set of guidelines used to assess and report the health and wellbeing of children and adolescents.
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Parents, guardians, or healthcare providers are typically required to file child and adolescent new to report relevant information about a child's or adolescent's health and development.
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