UNCG Psychology Clinic - Client Interest Form

Please correct the errors described below.
First & Last Name of person seeking services
of potential client
of potential client
If requesting services for yourself, skip this box
Please indicate if you are a parent/guardian, referring provider, etc.
There may be a slight delay to obtain an interpreter to contact clients in other languages; thank you for your patience!
Please note these forms are not monitored for safety concerns. If you are experiencing a mental health emergency, please contact 911; the Suicide & Crisis Line at 988, or the Therapeutic Alternatives Mobile Crisis Line at 1-866-626-1772 if you reside in or near Guilford County.
This is how we will contact you with more information

Thank you for considering the UNCG Psychology Clinic!

Your mental health matters and we are glad you reached out. We look forward to connecting with you.

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