Family/Co-Parent Counseling Contact Form
(PLEASE CHECK ALL THAT APPLY TO YOUR CURRENT SITUATION)
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Name: *
Contact Number: *
Contact Email: *
Are All Family Members Willing/Wanting to Participate in Counseling? *
Is Your Family Experiencing Any of the Following:  (Please Answer All Areas of Concern) *
Yes
No
Activity/Family Imbalance
Adolescent/Parent Conflicts
Adoption Issues
Alcohol Use
Anger Management
Anxiety
Blame
Blended Family Problems
Child/Parent Conflicts
Communication
Compulsive Behaviors
Death of a Child
Death of a Parent
Dependency Issues
Depression in Family Members
Disengagement/Loss of Family Cohesion
Eating Disorder
Extrafamilial Sexual Abuse
Family Activity Disputes
Family Business Conflicts
Family Member Separation
Family-of-Origin Interference
Financial Changes
Geographic Relocation
Incest Survivor
Infidelity
Inheritance Disputes Between Siblings
Interfamilial Disputes - Wills/Inheritance
Interracial Family Problems
Intolerance/Defensiveness
Jealousy/Insecurity
Life-Threatening/Chronic Illness
Multiple Birth Dilemmas
Physical/Verbal/Psychological Abuse
Religious/Spiritual Conflicts
Reuniting Estranged Family Members
Separation/Divorce
Sexual Orientation Conflicts
Traumatic Events
Unwanted/Unplanned Pregnancy
What Health Plan Does Your Family Participate In? *
If Other or Multiple Health Plans, Please List Below:
What is Your Family's Preferred Availability? (PLEASE LIST DAYS & TIMES) *
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