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First Name
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Last Name
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Name of Person Submitting this Form
Phone
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Phone Type
Work
Home
Mobile
Email
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Preferred Contact Method
Text
Email
Phone
Date of Birth
Method
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In-Person Only
Virtual Only
Hybrid Option
Preferred Provider
Please describe why you are seeking counseling:
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Availability: Days of the Week
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Availability: Time of Day
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Early Mornings (7a-9a)
Mornings (9a-12p)
Afternoons (12p-3p)
Late Afternoons (3p-5p)
Evenings (5p-8p)
Insurance Carrier
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Aetna
ASR
Blue Cross Blue Shield PPO
Blue Care Network HMO
Cigna
Mclaren Commercial
Medicare Part B
Medicare Plus Blue
Medicaid: Blue Cross Complete
Medicaid: Mclaren
Medicaid: Meridian
Medicaid: Molina
Medicaid: Priority Health
Medicaid: United Health Care
Priority Health Commercial
Priority Health Narrow Network
Self Pay
United Healthcare Commercial
Other - note below
Insurance Carrier - Other
Insurance ID
Referral Resource
Current Client
Psychology Today
Discharge Planner at Hospital or Facility
School Counselor/Counseling Center
PCP Referral
Social Media
Friends/Family
Insurance Company Directory
Counselor in the Community
Google Search
Other
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