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Intake Form
File Size:
39 kb
File Type:
doc
Download File
Confidentiality Agreement
File Size:
210 kb
File Type:
rtf
Download File
Preliminary Intake Form
*
Indicates required field
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Marital Status
*
Married
Single/Never Married
Divorced
Separated
In a Relationship
Email
*
Status
*
I am a Minor
I am NOT a Minor
Occupation
*
Employer
*
Are you taking any medication?
*
Yes
No
Prefer not to answer
Reason for Medication
*
Reason for Seeking Counseling. Check all that apply.
Choose Any
*
Marital Issues
Pastoral Counseling
Fears and Phobias
Financial Trouble
Over-eating
Insomnia
Recurrent Dreams
*
Alcoholism
Take Dangerous Drugs
Bad Home Conditions
Always Worried about something
Gambling
Job Problems
Depressed
Choose Any
*
Homosexuality
Sexual Problems
Thoughts of Suicide
Other
Please use this box to discuss any other information you feel will be helpful.
*
Submit
Payment Information
Finding Your Way, LLC accepts all major credit cards, personal checks and cash.
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