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  • English (US)
  • Identification Information


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  • Health Information


  • The following questions will be discussed during your visit. Please be prepared to disucss these questions and provide the requested information:

    1. Have you evern received counseling prior to this visit?
    2. If yes, what type of counseling did you receive?
    3. Who provided the counseling? (Please provide the name of person or certified professional.)
  • Religious Background

  • In Case of Emergency

  • Signature

  • I understand and agree to authorize Covenant Marriages, Inc., and Richard and Nephetina Serrano, The Marriage CEOs, and/or other staff to administer counseling procedures as deemed necessary:

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