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Childhood/Relational Family
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Client's Place of Birth
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Client's Family Biological/Adopt
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Client Adopted Age
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Client's # of Moves in Lifetime
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Client's Parents Married
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Client Raised by:
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Clients relationship with Parent/Guardian Figures:
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Client's # of Siblings(Name(s)/A
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Siblings (Name(s) and Age(s)
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Any family information/history you may find helpful:
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Relationships
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Client Marriage History:
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Current Relationship:
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Client's Children (names and age
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Are there any child custody issues involving you or your family?
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If yes, explain:
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Does you/your family have any CPS involvement?
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If yes, explain:
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Living/Home Current
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Patient Living
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2. Name / ages of all people living in the home.
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3. What stressors can you identify in your current families living arrangement/relationships?
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SPIRITUAL HISTORY
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Practice by Family
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Spiritual/Cultural Belief System
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Spiritual/Cultural Comments or concerns?
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