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Page 1: irp-cdn.multiscreensite.com · 2019. 11. 13. · Child's Name: Date of Birth Completed by: Adelita Segovia, M.D. Daniel B. Reising, M.D. Child and Adolescent Psychiatry General Psychiatry
Page 2: irp-cdn.multiscreensite.com · 2019. 11. 13. · Child's Name: Date of Birth Completed by: Adelita Segovia, M.D. Daniel B. Reising, M.D. Child and Adolescent Psychiatry General Psychiatry
Page 3: irp-cdn.multiscreensite.com · 2019. 11. 13. · Child's Name: Date of Birth Completed by: Adelita Segovia, M.D. Daniel B. Reising, M.D. Child and Adolescent Psychiatry General Psychiatry
Page 4: irp-cdn.multiscreensite.com · 2019. 11. 13. · Child's Name: Date of Birth Completed by: Adelita Segovia, M.D. Daniel B. Reising, M.D. Child and Adolescent Psychiatry General Psychiatry
Page 5: irp-cdn.multiscreensite.com · 2019. 11. 13. · Child's Name: Date of Birth Completed by: Adelita Segovia, M.D. Daniel B. Reising, M.D. Child and Adolescent Psychiatry General Psychiatry
Page 6: irp-cdn.multiscreensite.com · 2019. 11. 13. · Child's Name: Date of Birth Completed by: Adelita Segovia, M.D. Daniel B. Reising, M.D. Child and Adolescent Psychiatry General Psychiatry
Page 7: irp-cdn.multiscreensite.com · 2019. 11. 13. · Child's Name: Date of Birth Completed by: Adelita Segovia, M.D. Daniel B. Reising, M.D. Child and Adolescent Psychiatry General Psychiatry
Page 8: irp-cdn.multiscreensite.com · 2019. 11. 13. · Child's Name: Date of Birth Completed by: Adelita Segovia, M.D. Daniel B. Reising, M.D. Child and Adolescent Psychiatry General Psychiatry