Appointment Request Form
Name
Your answer
Are you a / Usted es
Client Phone Number / Número de télefono de la persona solicitando servicios (ex. xxx-xxx-xxxx)
Your answer
Is it alright to leave a Voicemail at this number?
Client E-mail / Correo electrónico de la persona solicitando servicios
Your answer
Type of service requested: /¿Qué tipo de consejería le interesa?
Language / Idioma
What language do you prefer to use in counseling?/¿Qué idioma prefiere usar en consejería?
Are you a City Heights resident? /¿Vive usted en City Heights?
Community Wellness Response Team
Required
Appointment Availability /Disponibilidad de tiempo para participar en sesiones de consejería
Please tell us SPECIFICALLY which days and times you are available for counseling/¿Qué días y horas prefiere? (i.e. Tuesday 12-5pm; Wednesday 2-7pm; etc)
Your answer
What brings you in to see us? ¿Cuál es el motivo por que esta solicitando servicios?
Your response can be brief. We will talk with you more about your reasons/Su respuesta puede ser breve.
Your answer
Where/how did you hear about us? / ¿Cómo supo de nuestra clínica?
Your answer
PERSON COMPLETING THIS FORM
Your Name / Nombre de la persona llenando esta solicitud
Your answer
Do you give us consent to contact referral source to complete referral process?
Nos autoriza para comunicarnos con la persona que recomendó estos servicios?
ADMIN USE ONLY / PARA USO ADMINISTRATIVO
Additional Preferences / Preferencias Adicionales
LGBTQ, gender, ethnicity, language, etc?
Your answer
Admin Initials/ Para uso administrativo
Your answer
Submit
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