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Therapy by
Cedric D'souza
MA. Clinical Psychology
Operating From:
Hungary (Online Sessions Only)
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HEALTH / COUNSELLING / LEGAL DATA
Are you presently under the care of any medical doctor / practitioner?
Yes
No
If yes, for what condition?:
Doctor’s name & Phone No.
Are you currently taking any prescription or non-prescription medications?
Yes
No
If yes, please indicate type and dosage & Prescribed by Dr.
Are you aware of any physical problems that impair your functioning?
Yes
No
If yes, please explain
Have you in the last 3 years received counseling, individual or
Yes
No
Have you ever been hospitalized or been in an outpatient program for emotional or substance abuse?
Yes
No
If yes, please list when, where and for what issue.
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