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Birthday
Day
Month
Year
Marital Status
Single
Married
Separated
Divorced
Widowed
Partnered
Other
How would you describe your health at the present time ?
Poor
Unsatisfactory
Satisfactory
Good
Very Good
Other
Do you consider yourself to be spiritual?
Yes
No
Would you prefer a particular gender of therapist?
Yes
No
If so kindly specify
Are you having problems with your quality of sleep?
Yes
No
Have you had any suicidal thoughts recently ?
Yes
No
If yes, how often?
Frequently
Sometimes
Rarely

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