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Age: Occupation: Maiden Name First Middle Status of Marriage: ( ) Married ( )Annulled ( )Separated: Legal Estranged ( ) Common-Law/Live-in ( ) Others 2. SOCIO-ECONOMIC BACKGROUND Family Relationship Major Family Problems Family Reputation in the Community ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ) Very Satisfactory ) Satisfactory ) Fair ) Poor ) No Apparent Problem ) Economic ) Mental/ Physical Illness ) Marital Problem ) One-Parent-Fam.

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