First Name
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Last Name
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Phone
Email
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Address
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Postal code
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Whom are you seeking counseling for?
Myself
My Partner and I
My Child
My Family
My Teen
As a Parent/Guardian
Kinship or Foster Child
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Briefly describe the issue you would like to work on.
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Do you have a preference for scheduling?
First available appointment
I’m not sure yet
Nicole Hadley, AMFT
Hailey Sattler, AMFT
Jessica Mitchell, LMFT
Doug Pierson, LMFT
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What is the date of birth of the client?
Preferred days and times for the appointments
Do you plan to use insurance?
Yes
No
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Name of Insurance
Insurance ID
Please upload the front and back of your insurance ID
How did you hear about Restored Pathways
Email Risk Acknowledgement and Use Consent
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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 therapists, providers, and/or office staff communicating with me via email or text message
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