Name *

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Address *

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Martial Status *

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Reasons for seeking therapy? (please check all that apply)

Depression

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Martial/Relationship issues

Medical problems

Financial stressors

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Suicidal thoughts of ideas

Panic attacks

Family issues (parenting, aging parents, etc.)

Anger management

Substance abuse

Other, please explain

Current conditions *

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Today's Date *

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Check this box to verify all of the above information is correct and you authorize Marla Ruhana to use your information for purposes of providing professional therapy services to you. *

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