First Name
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Last Name
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Phone
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Email
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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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Self
Couples
Child
Family
Parent/Guardian
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How would you like to receive services?
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In-Person Only
Telehealth Only
Open to Both
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?
Phone
Email
Text Message
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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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Yes
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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.
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