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Full Name
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Child’s Name
Phone
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Address
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City
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Email
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Whom Are You Seeking Therapy For?
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Whom Are You Seeking Therapy For?
Teen
Young Adult
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I'm Seeking Services For
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I'm Seeking Services For
ADD
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Relationship Issues
Eating Disorders
Grief/Loss
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Are you or your child currently on medication?
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Are you or your child currently seeing a Therapist/Counselor?
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Provide 3 Times You Are Available For Your Complimentary Consultation
What Is the Best Way To Contact You?
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Phone
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How Would You Like To Receive Services?
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In-Person Only
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Would you like to receive new information about mental health with Teens and Young Adults?
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How Did You Hear About Us?
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Email and SMS Text Message 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 have Open Hearts Therapy NYC therapists and/or office staff communicating with me via email or text message
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