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Rejuvenated Minds Therapeutic Services Consultation Form
We are so proud of you for taking the next steps towards your therapeutic journey.
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First Name and Last Name:
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Email Address:
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Phone Number:
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Age:
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Please provide your desired Pronouns
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State of Residence:
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Why are you seeking counseling services (Presenting Issue)
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What would progress (during therapy process) look like for you?
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Have you enrolled in therapy in the past?
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Current/ Prior Diagnosis or/ and Medication(s)
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Where did you locate our services?
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