New Client / Waitlist Questionnaire
Please complete this form to begin counseling or join my waitlist. I will do my best to contact you with my availability when I have an opening or to offer referrals when I cannot take on new clients. 
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Email *
Confirm email address *
Your name *
Your child's name *
Your child's age *
Reason for seeking help *
What type of service are you looking for? *
How did you find me?
What is your availability for appointments?

If I do not have immediate availability, would you like to be placed on the waitlist? *
Would you like referrals if I am unable to meet with you immediately?
What additional information would you like me to know?
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