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Email address:

Please provide a brief description of your counseling needs:

How did you hear about our practice:

Is CPS or the court system (including custody cases) involved with you or your family? If yes, please provide a brief summary.

First and Last name of person completing this form:

Phone number of person completing this form:

Client First and Last name (if different from person completing the form):

Client date of birth:

Photo of FRONT of insurance card:

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Photo of BACK of insurance card:

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Insurance Member ID

Insurance Group Number:

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