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The Care Center: 1:1 care through emotional, spiritual, and relational support during difficult seasons as well as counseling services.

About You

First Name

Last Name

Gender

Male Female

Birthdate

/ /

Marital Status

Mobile Phone

Email Address

What is the best way for us to reach you?

May we leave you a voicemail?

Yes No

What is your faith background? (You can say "none")

What church do you attend? (You can say "none")

About Your Situation

Please tell us how we can meet your need:

Where are most of your concerns centered?

When did your present concern begin to be a problem for you?

Please rate the severity of your present concern:

Would you like information about Counseling Services?

Yes No

Would you like information about any other services?

Classes Groups Church Information

I understand that the information that I included in this Intake Form will be discussed with the Clinical Director and Care Team Director to determine the best level of care.

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The Care Center

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About You

About Your Situation

Service Times

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