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Healing Strides Request for Counseling
This form is for the purpose of Healing Strides Counseling services
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* Indicates required question
Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
I am requesting services for
*
Choose
Self
My Minor Child
Couples Therapy
My Adult Child
My Spouse/Partner
Other (please explain in description)
Email
*
Your answer
Phone Number
*
Your answer
Insurance Provider
*
Your answer
What is your availability for appointments?
*
Your answer
Current Areas I would like to address
*
Depression
Anxiety
Relationship Issues
Grief
Divorce
Gender Identity/Sexuality
Suicidal/Self Harm Thoughts
Other
Required
Location Preference
*
In person
Telehealth
In person or Telehealth
Brief Description of why you are seeking services
*
Your answer
If you a re seeking services for another person please answer the following questions regarding that person
Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Phone Number if the person is over the of 18+
Your answer
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