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Potential Clients
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First Name
DOB
Gender
I am a Person Who Is : Choose One
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Size of Household: Select One
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Last Name
Race : Choose One
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Preferred Pronouns
Number om Children
Phone
Ok to Leave a Message
Yes
No
Best Time to Call
Email
Select an Address
I am Interested in: Choose One
Individual Counseling
Child/Adolescent
Couples Counseling
Family Counseling
LGBTQ+ affirming
The Primary Concern I Would Like to Talk Abot in Counsling is: Choose One
Anxiety
Depression
Anger Management
Family Issues
Life Stressors
Spiritual Concerns
School Related Stress
Grief
Gender Concerns
Loss of Employment
Selecting any of these may mean that yo are otapprpriate for participaton
Eating Disorder
Sexual Abuse
PTSD
Victim of Crime
Witness to Crime
Physical Abuse
Have you been hospitalised in te last 6 mos due to metal health concerns?
Yes
No
Are you taking or have you taken medications to address your mena health concerns
Yes
No
Are you seekin treatment fo alcohol or drug use?
Yes
No
Do you have health insurance
Yes
No
Are you seekin treatment mandated by the court or do you need an assessment?
Yes
No
I heard about the program from:
Are you completing this form on behalf of the client? If so, please include your name and relationship to the client in the field below.
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