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Client Intake Questionnaire
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Guardian First and Last Name
Your answer
Teen First and Last Name
Your answer
Guardian's Cell number
Your answer
Teen's Age
Your answer
Reasons for seeking counseling?
Your answer
Do any of these apply to your situation?
DCS Involvement
Sexual or Physical Abuse
Suicidal or Homicidal Ideation
Custody Concerns
Other:
If 'other' was selected, please explain.
Your answer
Preference for Male or Female Therapist?
Male
Female
No Preference
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