Selah Solutions Initial Consultation

INITIAL CONSULTATION

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Full Name*

First NameMiddle NameLast Name
Date*

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Phone Number*
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E-mail*
My Insurance ProviderAlcohol Safety Action ProgramCurrent/Former ClientPsychology TodaySelah Solution WebsiteEmployee Assistance ProgramOther
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Consultation for therapyASAP AssessmentBariatric AssessmentDept. of Transportation - SAPClinical Supervision
What concerns would you like to address?*
What would you like to see different in your life?*
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I am interested in being placed on the waiting list if appointments are not immediately available,
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INITIAL CONSULTATION