First Name
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Last Name
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Phone
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Email
*
Are you requesting services for yourself or someone else?
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Self
My child who is under 17
My adult child 18+
Couples Counseling
My relative or partner
Other
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Client's Age
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Preferred Therapist
How Did You Hear About Us?
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Google/Internet Search
Friend/Family Member
School Counselor
Pediatrician/Primary Care/MD
Social Media
Other
Your Message
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Email and SMS Text Message Risk Acknowledgement and Use Consent
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I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to our therapists and/or office staff communicating with me via email or text message
By providing my phone number, I agree to receive text messages from the business.
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