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Office Phone # 5035893112Empowering Choices Counseling Intake Paperwork 805 Liberty St. NE Suite 2, Salem, OR 1Office Fax # 5035893179Child/Adolescent New Patient Intake Form (online fillable)This
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Open the new-intake-child-adolescent-form-janda-2022docx file in a word processing program.
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Begin filling out the form by providing the child or adolescent's personal information, such as their name, date of birth, and contact details.
03
Proceed to the next section, where you will need to enter the child's medical history, including any previous diagnoses, medications, and allergies.
04
Fill out the section on the child's family history, providing information on any relevant medical conditions or hereditary diseases among immediate family members.
05
Continue by completing the section on the child's current symptoms or concerns, detailing any behavioral, emotional, or physical issues they may be experiencing.
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What is new-intake-child-adolescent-form-janda-docx?
It is a form used for intake of children and adolescents in the Janda program.
Who is required to file new-intake-child-adolescent-form-janda-docx?
Parents or guardians of children and adolescents participating in the Janda program are required to file this form.
How to fill out new-intake-child-adolescent-form-janda-docx?
The form can be filled out manually or electronically, following the instructions provided on the document.
What is the purpose of new-intake-child-adolescent-form-janda-docx?
The purpose of the form is to gather necessary information about children and adolescents entering the Janda program.
What information must be reported on new-intake-child-adolescent-form-janda-docx?
The form requires information such as personal details, medical history, and contact information of the child or adolescent.
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