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Richard Trotsky, Pay. D. Licensed Psychologist3630 Hill Blvd. Suite 204 Jefferson Valley, ADOLESCENT INTAKE FORM (PARENT SECTION) Adolescents Name: Date of Birth: Age: Male Female Race/Ethnic Origin:
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Start by gathering all the necessary information about your current household and family members.
02
Begin by filling out the details of your household, such as the address, number of people living in the household, and their relationship to you.
03
Provide accurate and up-to-date information about each family member, including their full name, date of birth, gender, and relationship to the head of the household.
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If any family member is not currently living in the household, indicate their current address or location.
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What is current household and family?
Current household and family refers to the individuals currently living together in a household and sharing resources and responsibilities.
Who is required to file current household and family?
Any individual or head of household who is responsible for managing the household and family is required to file current household and family.
How to fill out current household and family?
To fill out current household and family, you need to provide information about all members living in the household, their relationships, sources of income, and any other relevant details.
What is the purpose of current household and family?
The purpose of current household and family is to provide a snapshot of the individuals living together in a household, their relationships, and their financial situation.
What information must be reported on current household and family?
Information such as names of household members, relationships, sources of income, expenses, and any other relevant details must be reported on current household and family.
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