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Full Name
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Phone
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Address
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City
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Postal code
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Email
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Child's Name (if applicable)
Child's Age (if applicable)
Client's Age
I'm Seeking Services For
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I'm Seeking Services For
Anxiety
Depression
ADHD
OCD
Substance Abuse
Other
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Whom Are You Seeking Counseling For
Self
Couples
Child
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Parent/Guardian
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Types Of Services
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Which type(s) of service are you seeking?
Counseling
Testing & Evaluation
Psychiatry
Career Testing Program
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Psych Testing Report Forwarding Requirements
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Is there an institution or school that will require any reports we generate?
No, we are looking for your services and don't anticipate others will need a report
Yes, we hope you can share information with other providers (such as counselor or medical professional)
Yes, we hope to use any resulting report to assist with starting Special Education procedures
Yes, we hope to use any resulting report to assist with college-related accommodations
Other
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Insurance Verification (If you plan to utilize your insurance)
Date of Birth of Client
Name of Insurance
Insurance ID
Front of Insurance Card (Picture)
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Back of Insurance Card (Picture)
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Provide 3 Times You Are Available For First Appointment
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Briefly Describe The Issue You Would Like to Work On
What Is the Best Way To Contact You?
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Phone
Email
Text Message
How Would You Like To Receive Services
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In-Person Only
Telehealth Only
Open to Both
Would you like to receive our best parenting advice sent to your email?
Yes
No
How Did You Hear About Us?
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Email & 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 Clarity Centers clinicians and/or office staff communicating with me via email or text message.
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