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Please provide the following information which will remain confidential.

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* 1. First Name

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* 2. Last Name

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* 3. Have you ever had previous counseling?

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* 4. Age

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* 5. PLEASE SUMMARIZE YOUR SPECIFIC GOALS AND EXPECTATIONS FOR THIS GROUP

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* 6. The group will meet on Tuesdays from 5:30- 6:45. Are you available during this time?

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* 7. How did you hear about the group?

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* 8. Contact Information (phone number & email address)

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