First Name
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Last Name
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Phone
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Address
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Postal code
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Whom Are You Seeking Counseling For
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How would you like to receive services?
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In-Person Only
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Provide 3 Times The Client Is Available for Counseling (Monday-Friday)
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Briefly describe the issue you would like to work on.
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Would your like first availability or work with a specific clinician?
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First Availability
Insert Clinician Name
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What's the Best Way to Contact You?
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Were you hoping to use your insurance? If so, please list your insurance plan information.
Would you like to receive information about coping strategies and self-care sent to your email?
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How did you hear about us?
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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 Lyons Center LLC therapists and/or office staff communicating with me via email or text message. By submitting, you agree to receive text messages at the provided number from Lyons Center LLC (478-777-5824 or 478-227-0779). Message frequency varies, and standard message and data rates may apply. You have the right to OPT-OUT receiving messages at any time. To OPT-OUT, reply "STOP" to any text message you receive from us. Reply HELP for assistance."
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