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New client intake form
1
Name
please enter the name of the person to receiving counselling
First Name
Last Name
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2
Is the person under 18?
YES
NO
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3
Contact name
Please list the name of a parent or guardian here.
First Name
Last Name
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4
Contact phone number
Area Code
Phone Number
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5
Briefly describe the issues related to your child or teen
This will be used to best match a counsellor for you
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6
Are there any specific areas where you require support?
This is used to help best match you to a counsellor.
Anxiety
Addiction
Depression
Financial worries
Low self-esteem
Relationship issues
Other
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7
Other
If you have any other information that you think we should know, please provide it here.
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8
Consent
*
This field is required.
I consent to having my personal data securely stored in order for Northstar to respond to my enquiry. I have also read the
terms and conditions
with regards to privacy.
I consent & have read the terms and conditions
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