Consultation Screening Form
Demographics:
Email address *
Privacy Information
Notice: This is not a 100% secure HIPAA compliant form. It is intended to collect brief information to prepare for the consultation. If you are concerned with keeping this information private, no worries, please contact the counselor by phone. If you choose to complete this form, your data will be stored for further communications related to a consultation with the professionals at Creating Sustaining Joy, LLC.
Name *
Address *
Would you like to receive email communications? (Please note that HIPPA states that email is not the most secure method). *
Required
Is it okay to leave a voicemail and/or text messages? (Please note that HIPPA states that these communication methods might not be the most secure method). *
Required
Phone number *
What is your age? *
What is your ethnicity?
What is your date of birth? *
What is your gender identity?
Are you...? *
We serve clients who are Deaf or Hard-of-Hearing ALSO, please indicate your communication preference? *
How were you introduced to us? If you found us online, please share the words you searched to find us?
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