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Client Information Sheet

Insurance Information

Present/Past History

Have you had or do you presently have any of the following conditions? (Check if yes.)

Current Medical Conditions


Family History

Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.) In addition, please identify at what age the condition occurred.

Safety &Crisis Prevention Plan

Authorization To Transport Minor Children

I authorize the staff of Cross Over Therapy, LLC to transport the following minor child(ren), for whom I am the parent or legal guardian:

Home Safety Questionnaire