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Welcome to Grand Island Mental Health & Medical Clinic!

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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    Check all that apply.
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    Check all that apply.
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    Ex: It has been 3 years and I was 32 years old.
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    Check all that apply.
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    Ex: It has been 3 years and I was 32 years old.
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    Select all that apply.
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    Please choose all that apply.
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    Please choose all that apply.
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    Please choose all that apply.
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    Please list information about all of your children
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    I am the _____ (st/nd/rd/th) sibling in a line of _____ siblings.
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    Please choose all that currently apply.
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    Please list all past care.
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    Please list all previous care.
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    Please indicate the symptoms you are CURRENTLY experiencing and HOW LONG you have experienced them
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    Please indicate if you 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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    (This includes social drinking and any prescription drug not prescribed to you)
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    Please Select
    • Please Select
    • Currently serving
    • Honorably discharged
    • Dishonorably discharged
    • Other than honorably (OTH) discharged
    • General discharge
    • Bad conduct discharge
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    Please choose all that apply.
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    College, University, Trade or Other?
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    Please Select
    • Please Select
    • Yes, obtained diploma
    • Not completed
    • GED obtained
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    • Please Select
    • Yes, obtained diploma
    • Not completed
    • GED obtained
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    Please list any and all medication you are currently taking or have taken (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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    Form Completed on:
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