• Intake Form: Linda J. Cooke, LCSW

  • Please provide the following information as accurately as possible. Please note: information you submit here is protected as confidential information.

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  • GENERAL HEALTH AND MENTAL HEALTH INFORMATION

  • FAMILY MENTAL HEALTH HISTORY

  • In the section below identify if there is a family history of any of the following. If yes, indicate the family member's relationship to you (father, grandmother, uncle, etc.).

  • ADDITIONAL INFORMATION

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  • Should be Empty: