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Glitters

Intake form

Birthday
Day
Month
Year

What is your request for help?

What feelings or emotions do you experience?

How long have you been experiencing this problem?

What have you done so far to resolve it? Have you had therapy/coaching before? What helped and what didn't help?

What would you like, what is your desire?

Are you experiencing any other health problems?
Yes
No
Have you currently or in the past had psychological complaints such as psychoses?
Yes
No
Do you take medication?
Yes
No
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