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Health Information Form

Please complete the SECURE on-line form below.

Health Information Form

Please check any symptoms that describe how you feel, think, or behave currently or within the last 3 months:

Has any member of your family been hospitalized for mental health concerns?

Do/did you have any family members who have/had problems with drinking alcohol or using drugs?

Has any member of your family attempted/committed suicide?

Have you ever seen a counselor, psychologist, psychiatrist, or other mental health professional for any mental health or drug/alcohol concerns?

Have you ever been hospitalized for mental health or drug/alcohol concerns?

Do you have thoughts of harming yourself?

Have you ever tried to harm yourself?

Did you receive medical help at the time?

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tiftareapacs.com

Tiftarea Psychiatric and Counseling Services, LLC. | Office Address: 223 East 2nd Street Suite B Tifton, Georgia 31794
Phone: 229-339-3721 | Fax: 229-472-9151 | Mailing Address: Post Office Box 1613 Tifton, Georgia 31793
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