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Welcome to Grand Island Mental Health & Medical Clinic! (Minor Child Form)
We are excited to get to know you better! 
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    (Ex: If treatment was successful in what ways would you be able to tell?)
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    Choose all that apply.
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    Choose all that apply.
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    Ex: It has been 3 years and the patient was 10 years old.
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    Choose all that apply.
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    Ex: It has been 3 years and the patient was 10 years old.
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    Choose all that apply.
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    Choose all that apply.
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    Choose all that apply.
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    Choose all that apply.
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    If the patient has children, please list all children and information.
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    If the patient has siblings, please list all siblings here.
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    Choose all that apply.
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    Please list all persons currently living in the patient's home.
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    Please list information about all previous mental health treatment.
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    Please list information about all inpatient treatment.
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    Please indicate the symptoms the patient is CURRENTLY experiencing and HOW LONG the patient has been experiencing them.
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    Please indicate if the patient or a family member has been diagnosed with any of the following:
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    If there is currently any suicide risk please seek help and call the National Suicide Hotline at 1-800-273-8255
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    If you responded "none" to all questions please write n/a.
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    Choose all that apply.
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    Please choose all that apply.
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    Please list all elementary, middle, and high school the patient has attended.
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    Please list any and all medications the patient is currently taking including over the counter medications
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    (You can ask for a copy of these Terms, Conditions, and Client Rights and Responsibilities at any time)
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    The easiest way to get information quickly is by "liking" and checking our Facebook page for holiday and weather related closings and office updates 
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