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Freedom To Be. To Belong. To Become. 

Intake Form

This form is designed with the intention of getting to know you as we begin this relationship. It will offer you the framework and structure for our work together. Clarity and understanding will offer us an opportunity to co-create a safe space and healthy boundaries for our work relationship. The information you share will be kept strictly confidential. 

Have you ever been hospitalized for psychological or psychiatric reasons?
Please mark "tick" against items that are relevant t you
Please describe any current significant or stressful life events that you have been experiencing:
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