Adult Counseling Contact Form
(PLEASE CHECK ALL THAT APPLY TO YOUR CURRENT SITUATION)
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Name: *
Contact Number: *
Contact Email: *
Are You Experiencing Any of the Following:  (Please Answer All Areas of Concern) *
Yes
No
Anger Control Problems
Antisocial Behavior
Anxiety
Attention-Deficit/Hyperactivity (ADHD)
Bipolar Disorder - Depression
Bipolar Disorder - Mania
Borderline Personality Disorder
Childhood Trauma
Chronic Pain
Cognitive Deficits
Dependency
Dissociation
Eating Disorder and Obesity
Educational Deficits
Family Conflict
Female Sexual Dysfunction
Financial Stress
Grief/Loss Unresolved
Impulse Control Disorder
Intimate Relationship Conflicts
Legal Conflicts
Low Self-Esteem
Male Sexual Dysfunction
Medical Issues
Obsessive-Compulsive Disorder (OCD)
Panic/Agoraphobia
Paranoid Ideation
Parenting
Phase of Life Problems
Phobia
Posttraumatic Stress Disorder (PTSD)
Psychoticism
Sexual Abuse Victim
Sexual Identity Confusion
Sleep Disturbance
Social Anxiety
Somatization
Spiritual Confusion
Substance Use
Suicidal Ideation
Type A Behavior
Unipolar Depression
Vocational Stress
What Health Plan Do You Participate In? *
If Other or Multiple Health Plans, Please List Below:
What is Your Preferred Availability?                                    (PLEASE LIST DAYS & TIMES) *
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