Full Name
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Child's Name
Phone
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Email
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Address
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Child's Age
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Relationship to the Child
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Your Relationship to the Child
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Whom are you seeking counseling for?
Whom Are You Seeking Counseling For?
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How would you like to receive services?
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Open to Both
Interested in joining an 8-week Circle of Security Parent Group?
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Please Provide 3 Times Your Child Is Available for Counseling
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Would your like first availability or to work with a specific clinician?
(select all that apply)
First Availability
Liz Blaha
Lydia Alter
Jonathan Caes
Elizabeth Doppler
Taylor Simerly
Carly Schrimpl - Telehealth Only
Cheryl Welsh
Susan Stutzman
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What's the Best Way to Contact You?
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Have You Read Our Private Pay Policy?
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Would you like to receive our best parenting advice sent to your email?
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How did you hear about us?
Briefly describe the issue you would like to work on.
Email Risk Acknowledgement and User 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 Kid Matters therapists and/or office staff communicating with me via email or text message
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