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Australian Institute for Narrative Care

PERSONAL DETAILS: Please take note of the fact that this information will be treated confidentially!
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Today's Date: dd/mm/yy
Name & Surname
Date of Birth, Age & Gender
Telephone number: Home; Mobile; Work
Address: Home; Mail; E-mail
Preferred Method of Contact
Marital Status & Names of Family Members
Occupation
Religious Affiliation
Referred by
Name & telephone number of your General Practitioner (will only be contacted with your approval or when your health or well being is significantly threatened)
Previous or on-going counselling / therapy / treatment (Have you had any before? What sort? For how long? What was the outcome?)
Try to put the specific problem you seek help with, in a few sentences
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