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Interested Client | Decorah Counseling Collective
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If you are completing this form for someone else (ex: your child) please list
YOUR
first and last
name
and
relationship
to the client:
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Client First and Last Name
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Contact Email
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Contact Phone
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Age
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Gender Identity and Pronouns
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Why are you are seeking counseling at this time?
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Do you have a specific therapist in mind?
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No preference
Betsy Peirce LMHC
Madie Miller tLMHC
Mariah Smith LMHC
Tracy Essa tLMHC
Yarrow Pasche tLMHC
I am interested in
*
Individual (one-on-one) counseling
Couples and relationship counseling
Family counseling
Parent Child Interaction Therapy (PCIT)
I am looking for
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In-person in Decorah, Iowa
Telehealth (client must be located in Iowa)
What insurance carrier do you have?
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How did you hear about us?
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