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  • Client #1

  • IF above client is a minor, use parent/guardian information in this next section- Otherwise, please fill out client information in this section

  • IN CASE OF EMERGENCY CONTACT INFORMATION

  • WHO REFERRED YOU TO US?

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  • If Client #1 is a minor, you MUST click "YES" to add the parent/guardian name!

  • ADDITIONAL COUNSELING PARTICIPANTS OR AUTHORIZING ADULTS

  • Should be Empty: