Intake Questionnaire
Thank you for being interested in our Counseling Services! Please fill out the following questionaire and we will respond to you with some available openings within one business day. 
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Please provide the name of the person completing this form: *
Please provide your email and phone number to best contact you: *
I want an appointment for... *
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Client's first & last name *
Client's birth date *
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Which locations were you interested? (Select one or more) *
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What are some presenting issues or things you are hoping to address in therapy?  If you chose "family therapy" please disclose each family members' age and relation in the description. *
Did you have a preference of one of our therapists at our practice?
Would you be intersted in working with our Master level interns? *
Available days for the appointment (Select one or more) *
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When are you available for an appointment start time? (Select one or more) *
Required
How did you hear about us? *
Are you interested in using your medical insurance plan or be a self pay client? *
Have you seen any other Mental Health Provider this year? *
If using insurance, please select your insurance carrier that we are in-network providers with:
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What is your preferred method of contact? *
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