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This is a confidential form. All services will comply with HIPAA confidentiality standards.
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Are you suicidal? YesNo
Which paid service are you requesting? CounselingPsychotherapyDream TherapyDreamWorkLife CoachHuman Design
Would you prefer online counseling, face-to-face counseling (in person), or both? OnlineIn-PersonBothI don't know
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Or contact Chris directly at (479) 308-1901
