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Intake Form
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Patient Full Name
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Reason For Counselling (Select all that apply):
Abuse
Addiction
ADHD
Anger
Anxiety
Autism
Bullying
Depression
Eating Disorder
Family
Grief and Loss
Learning Concerns
Obsessive Compulsive
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Parenting Issues
Post Traumatic Issues
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Self-Harm
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Sleeping Concerns
Stress
Trauma
Body Image Issues
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