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5PEAKS Consultation Intake Form
Please fill out the online form and submit before our initial session.  I look forward to meeting with you.
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Full Name *
Date of Birth *
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Phone Number
Email Address *
Mailing Address *
Marital Status *
Do you have children? *
Occupation *
Hobbies/Interests *
Please describe your support system *
What's important to you? *
What is your motivation for scheduling an appointment? *
What goals do you have?  What would you like to get out of our time together? *
What are your strengths? *
Where did you hear about 5PEAKS/Jennifer Van Rossum, MA, LPC? *
5PEAKS has a 24 hour Cancellation Policy to avoid the session fee. *
DISCLAIMER AND WAIVER OF LIABILITY:  By signing my name below, I expressly acknowledge and agree to all of the following. 1) This service specifically does not offer any therapeutic services and is solely for educational and consultation purposes. 2) While the service may be conducted by a Licensed Professional Counselor, the program is NOT providing any clinical services and does not constitute therapy. 3) No therapeutic client/patient relationship is created by my attendance in this service. 4) This service is not intended to treat any of the participants. 5) I hereby hold harmless and release, waive, discharge and covenant not sue Jennifer Van Rossum/5Peaks, LLC from any and all claims associated with my participation in the service.  I further expressly agree that the foregoing waiver is intended to be as broad and inclusive as is permitted by the law of the State of Wisconsin. 6) I agree to indemnify and hold Jennifer Van Rossum/5Peaks, LLC harmless from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorneys' fees brought as a result of my involvement in the program. 7) If any portion of the Disclaimer and Waiver of Liability is held invalid, the remaining portions shall, notwithstanding, continue in full legal force and effect. *
Electronic Signature of Full Name (of parent if under 18) *
Today's Date *
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