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Loved Ones of First Responders Support Group Intake Form
www.AvedianCounselingCenter.com (818) 990-0999
EMMA EKUM, M.S., LMFT
Sherman Oaks - Glendale
California License # LMFT 111175
(818) 438-0830
Client Registration
Name:
*
DOB:
*
Age:
*
Full Address:
*
Cellular Phone:
Is it okay to leave a message?
Yes
No
Work Phone:
Is it okay to leave a message?
Yes
No
Email Address:
Family Physician:
*
Phone Number:
*
Therapist or Psychiatrist (if any):
Phone Number:
Assigned (Legal) Gender
Gender Identity
Preferred Pronouns
Sexual Orientation
Racial Identity
Do you have kids
Yes
No
if yes, how many
What age(s)
Relation to First Responder:
*
What is the occupation of your First Responder loved one?
*
Any Present Symptoms in Yourself:
*
Previous Therapy:
*
Briefly Describe Living Situation:
*
Employment:
*
Date of First Symptoms:
*
What are the Symptoms?
*
Current Medications:
*
Other Pertinent Drug/Alcohol History:
*
Person to Contact in Emergency:
*
Phone Number:
*
How did you hear about us?
Date of First Office Visit: