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Client Intake Form

Please fill out the following form
so I can tailor support specifically to you!

(Confidentiality is implied by submitting this form.)

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Are you currently in therapy or working with another mental, emotional, or physical health professional?
Are you currently in therapy or working with another mental, emotional, or physical health professional?
Do you have children? (Check all that apply).
Have you experienced any suicidal ideations / acts that have been not been addressed with a medical / psychiatric professional?
Are you currently taking any medication used for the support of emotional and/or mental health?

Thanks for submitting!

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