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MEMBERSHIP APPLICATION Name: ___, DOB: ___, Mailing Address: ___, ___. Home Phone: (___)___, Cell Phone: (___)___. Email (to receive club news and billings): ___. In case of an emergency please notify:

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Step 1: Gather all necessary information and documentation about the individual being assessed and consulted.

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Individuals who require a comprehensive assessment of their mental health and well-being.

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