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New Client Interest Form
Complete this form to let us know you're interested in connecting!
One of our team members will reach out to discuss scheduling your first session.
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Email
*
Your email
Phone Number (Adult Client OR Minor's Guardian) (include area code)
*
Your answer
What services are you seeking?
*
Professional Counseling
Recreational Therapy
Other:
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If you selected Professional Counseling; Are you seeking Virtual/Tele-Health or In person Counseling?
Seeking Virtual Counseling
Seeking In-person Counseling
Seeking In-Person, but willing and able to do Virtual/Telehealth
Other:
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Client Name (Last, First)
*
Your answer
Referring Persons Name and Title
*
Your answer
How do you intend to pay for therapy services?
(Insurance; Name Specific Provider) (Cash/Private Pay) etc.
*
Your answer
Referral Source (How did you learn about Grounded Therapy Network)
*
Your answer
Additional Information you would like us to know
Your answer
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