Form34 - [FORM 34-Use the top of this page for your...

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[ FORM 34 —Use the top of this page for your letterhead.] Young Adult Information Form Note : Unless there is a serious risk of injury to you or someone else, the information on this form is confidential. It will not be discussed with your parents without your consent. Your name: Today’s date: Your age: Your address: Phone #: Health How tall are you? How much do you weigh? What do you consider your ideal weight? What physical or medical problems do you have now, or have you had in the past? Family Birth parents’ names: and Address: Phone #: Present parents’/guardians’ names: and Address: Phone #: How would you describe your parents’ relationship? What kinds of problems are you having with: Parents/stepparents/guardians? Parents’ live-in friends or boyfriends/girlfriends? Brothers or sisters (or stepbrothers or stepsisters)? FORM 34. Information form for young adults (p. 1 of 3). Adapted from a form devised by Nora Fleming Young, PhD, of Mayer, AZ, and used by permission of Dr. Young.—From
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Form34 - [FORM 34-Use the top of this page for your...

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