Child's Name & Age (if child is prospective client)
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If you feel comfortable, please provide a brief description of your needs and what leads you to seeking therapy at this time. This may include symptoms, and / or goals for therapy.
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How did you hear about Alexandria Art Therapy? If a provider referred you, please include their name.
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Do you plan to use insurance benefits?
I would prefer to attend sessions:
For virtual services, in what state are you located?
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Availability (please select all that apply):
Other comments, questions, or things you would like us to know:
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