Full Name
Child’s Name (if necessary)
Child's Age (if necessary)
Phone
*
Address
*
City
*
Postal code
*
Email
*
For whom are you seeking counseling?
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Child
Parent/Guardian
Adolescent
Adult
Family
Couples
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Relationship to child or adolescent (if applicable)
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Parent
Guardian
Other
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Would you prefer a male or female counselor?
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Male
Female
No preference
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Would you like to receive online counseling (telehealth)?
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Yes
No
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Please provide at least 3 times you or your child/adolescent are available for counseling.
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What is the best way to reach you?
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Phone call
Text Message
Email
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What type of therapy are you seeking?
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Couples Counseling
Child Counseling
Individual Counseling
Parent-Child Relationship Therapy
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Yes
No
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Would you like to receive our best counseling and relationship advice sent to your email?
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Yes
No
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How did you hear about us?
Briefly describe the issue(s) you would like to address. Is there a specific therapist you’re hoping to work with?
Email Acknowledgement & Use Consent
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 Silver River Counseling therapists and/or office staff communicating with me via email.
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