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Active Rehab Centre

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Psychotherapy Intake
Form

Psychotherapy

Intake Form

    Medications

    Are you currently taking any medication(s)?

    PrescriptionOver the counterSupplements

    Stressors

    Are any of the following stressors a constant in your life?

    SmokingAlcoholCoffee / Caffeinated DrinksRecreational drugs

    Agreement

    I confirm that the information I have provided is accurate to the best of my knowledge and authorize the release of my medical condition to my family physician.

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