INTAKE FORM - THINK POSSIBILITIES COUNSELING SERVICES, PLLC
1.
Are you interested in counseling for yourself or someone you care about?
myself
a minor child or youth in my care
my significant other
myself and a minor child or youth
myself and a significant other
all of the above
2.
Briefly describe the challenges or issues you are facing.
3.
We specialize in services for individuals and their families related to adoption, kinship caregiving, separation/divorce, or blending families. Which of these concerns is of interest to you?
4.
How soon do you need counseling, and at what level?
This is prevention. I am looking for options for the near future.
This is s pressing issues, I need counseling within the next month
I am motivated, I need counseling in the next couple of weeks
I have an issue I would like to address within the next week
This is urgent
5.
This is preventative, and I am looking for options for the near future.
This is pressing, and I need counseling in the next month or so.
I am motivated, and I need counseling in the next couple of weeks.
I have an issue that I would like to address in the next week.
This is urgent.
Your Contact Information:
6.
The best email address to contact you
7.
We will get in touch with you in the next 24 to 48 hours. If you have not heard from us in 48 hours, please email drglendaclare@gmail.com to make sure something was not missed. Thank you!
Current Progress,
0 of 7 answered