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Get Wild Tree Psychotherapy Wellness Personal History Form — Child/adolescent

Nder Identity: Sexual orientation: *Feel free to use the back of the page to expand on explanation for any question PRESENT CONCERNS & SYMPTOMS Primary concern(s)/why seeking therapy: Current symptoms: Concerning behaviors: How long have these symptoms/behaviors been present? Describe any recent major changes in life: Any recent changes in: Sleeping Eating Self-Perception Other: Any history of verbal/emotional, physical, or sexual abuse: Concerns regarding self-harming tho.

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