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Get 1915(c) IA v1 2012-2022

Icity:   Gender:   Gender Expression:  Parent/Primary Caretaker Name: (first, middle, last)  Legal Guardian Name: (first, middle, last)  SSN:  Is this person, the legal guardian?  □ Yes  □ No (if not, enter information below)  Phone Number:  Title/Department:  BEHAVIORAL HEALTH HISTORY  I. CHIEF COMPLAINT (Major symptoms, difficulties, and/or Issues as they relate to behavioral health –in client’s/caretaker’s own words/quo.

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