First Name
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Last Name
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Phone
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Address
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Whom are you seeking counseling for
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How would you like to receive services?
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Briefly describe the issue you would like to work on.
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Would you like first availability or work with a specific clinician?
First Available
Liz Lee
Paul Lucht Rutledge
Kara Goldmann
Adam Wick
What time of day are you usually available for appointments
Morning (8am-noon)
Afternoon (Noon-5pm)
Evening (5pm-8pm)
Insurance Verification (Optional)
Date of Birth of Client
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Insurance Carrier
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How did you hear about us? (dropdown)
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What's the Best Way to Contact You?
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