Appointment Request
Client's First Name
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Client's Last Name
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Client's Date of Birth
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If you are seeking counseling for someone other than yourself, what is your name and relationship to the client?
Email
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Phone
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What's your preferred method of contact?
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Phone
Email
Both
Who are you seeking counseling services for?
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Myself
My child
My adolescent
Me and my partner/spouse
My family
Briefly describe what you want to work on in counseling. This helps us determine which of our therapists would be a good fit for you.
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What day(s) do you prefer to have your appointment?
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What time of day works best for your appointment?
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My schedule is flexible.
9AM - 11AM
12PM - 3PM
4PM - 7PM
How Would You Like To Receive Services
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In-Person Only
Telehealth Only
Open to Both
Do you plan to use insurance for counseling services?
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Yes
No
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How did you hear about us?
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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 Life Enrichment Counseling therapists and/or office staff communicating with me via email or text message.
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