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Behavioral Health Intake Form

Substance Abuse • Mental Health Counseling • Anxiety Counseling

Name*

Phone*

Email*

Address*

Male or Female?*

Date of Birth (mm/dd/yyyy)*

Emergency Contact Name*

Emergency Contact Phone*

Insurance Provider

Policy Number

Name of Primary Insured

Insurance Card

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NEWLIFE WELLNESS BEHAVIORAL HEALTH

25524 Goddard Rd Taylor MI 48180

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