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Whom Are You Seeking Counseling For
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Date of Birth (If parent requesting services for child, use child's DOB)
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Insurance or Self-Pay
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What areas of concern would you like to work on?
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Depression
Anxiety/Worry
ADHD
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Trouble with school or work
Difficult family dynamics
Relationship challenges
Mood Disorders
Difficulty with Anger
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Which in-person location fits best for your in-person appointments?
New Market, Frederick, Boonsboro
New Market
Frederick
Boonsboro
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Subscriber DOB
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Email 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 Green Valley Therapy therapists and/or office staff communicating with me via email or text message
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