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General Affordable Counseling - Appointment Request
Upon submission of this form, your requested staff member will reach out within 24-48 business hours.
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* Indicates required question
Email
*
Your email
Please provide a brief description of your counseling needs:
*
Your answer
Which Counseling Intern is preferred?
Choose
Anthony Marcello
Hayley Hayes
Lauren Swilley
Meghan O'Brien
Nicole Wilson
Rebecca Capps
Sarah Hutchinson
Steven Chambers
What are you looking for in a counselor?
*
Your answer
How did you hear about our practice?
*
Your answer
First and Last name of person completing this form:
*
Your answer
Phone number of person completing this form:
*
Your answer
Relationship to client:
*
Self
Parent/Guardian
Client first and last name (if different from person completing this form):
Your answer
Client date of birth
*
MM
/
DD
/
YYYY
Client address (street address, city, state, zip):
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Your answer
Emergency contact name (First and Last):
*
Your answer
Emergency contact phone number:
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Your answer
Emergency contact relationship to client:
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Your answer
The $40.00 Intern fee is not covered by insurance and will be considered a self-pay fee.
Please initial here to agree to these terms:
*
Your answer
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