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Kevin Russell, R. Psych. Suite 500, 5940 MacLeod Trail SW Calgary, AB, T2H 2G2 Phone: (403) 6510723Intake Form Please provide the following information and answer the questions below. Please note:

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Anyone seeking services or assistance from a mental health provider may need to fill out an intake form.

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The intake form - mind is a document used to collect information about a person's mental health history, current symptoms, and treatment goals.

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