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602-830-8400
info@flourishfamilypsychiatry.com
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Intake Form
First name
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Last name
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Email
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Phone
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Birthday
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Month
Day
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Emergency Contact
Are You Currently Taking Any Medication?
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If Yes, What? Include Any Controlled Substances. If not taking medication, write "none"
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What Issues Are You Seeking Help With?
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ADHD/Focus
Depression/Mood
Anxiety
Bipolar Disorder
Sleep
OCD
Autism Associated Concerns
Perinatal/Postpartum Concerns
Trauma/PTSD
Behavior Concerns
Other
What State Do You Reside In?
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Will You Be Using Insurance?
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How Were You Referred To Us?
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Service Locations
Arizona, Colorado, Nevada, and Oregon
Operating Hours
Scheduling varies by Provider
Questions?
Phone: 602-830-8400
info@flourishfamilypsychiatry.com
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