Intake Form
This form should be filled out in order to receive services.
Your Name
Your answer
Your phone number
Your answer
Your email address
Your answer
Reason for seeking counseling. Please be as detailed as possible.
Your answer
Level of Service
Preferred Day Preferred Time
9:00 am
10:00 am
11:00 am
1:00 pm
2:00 pm
3:00 pm
4:00 pm
6:00 pm
7:00 pm
Tuesday
Wednesday
Thursday
Would you like a 30 minute free consultation?
Did you read the HIPPA Compliance on the website?
Please understand that a part of HIPPA Compliance is that you should be in a safe and secure environment when we are having sessions. This will help to ensure your privacy. Do you understand your role in the counseling process?
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