Intake Form

Background Information
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Current Issue
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Symptom Checklist




Medical History
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Please list your current medication(s):




































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Alcohol & Drug Use


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Education
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Employment












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Family of Origin
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Current Relationships
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Social History
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NorthStar Psychological + Consultation Services, LLC
429 E. Vermont Street
Suite 307
Indianapolis, IN 46202
Phone:
317-572-7847 (ST4R)
Fax:
317-632-3253
eMail:
info@northstarpsych.com
Hours:
Monday through Thursday 8:00 a.m. to 8:00 p.m. Closed all other days.