Intake form

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What is your age range?

What is your primary motivation for seeking therapy?

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Overcoming addiction

Improving self-esteem

Building healthy relationships

Managing stress

Seeking support for a partner

How did you hear about us?

What specific challenges are you facing?

Have you previously sought therapy for this issue?

What type of therapy are you interested in?

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Individual Therapy

Group Therapy

Couples Therapy

Online Therapy

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