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Counseling Inquiry Form
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Please note, if this is an emergency situation, refer to our crisis resources, linked
here
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First Name
Last Name
Email
Cell Phone
Birth Date
Availability
Membership Status
Non Member/non-regular attender
Member/Regular attender
Type of Service
Individual Counseling
Family Counseling
Couples Counseling
Parent Consultation
Premarital Counseling
ADHD Assessment
EMDR Therapy
Play Therapy
Peferred Method of Contact
Email
Phone
Reason for seeking counseling
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