Online Demographics Form Download and/or print the demographics form Dan McGann Therapy Inc. Demographics: Client Information Please complete the full form as best as you can. All questions are optional answer. * Email is required to send you a copy. Email * Date Address Name Telephone Number (Day) Telephone Number (Evening) Occupation By whom were you referred? Significant relationship status? singleengagedmarriedseparatedcommitted relationshipdivorcedwidowedremarried Any children? yesno List children's name, age, gender: Whom have you previously consulted about your present problem(s)? Are you taking any medications? If "yes", what, how much, and with what results? What do you expect to accomplish from therapy, and how long do you expect therapy to last? Please add any information that may aid me in understanding and helping you

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