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      You Have a Friend Counseling Service

      Client Appointment Request Form

      You Have a Friend Counseling Service are provided based on the Ethical Standards of the American Counseling Association.  Your request for services and the information you share are considered confidential in accordance with these standards.  No information will be released without your written consent.  Please review the limits of confidentiality on the Consent for You Have a Friend Counseling Service information sheet.

      Fields marked with an (*) are required.

      Appointment Scheduling Information

      Name*:
       First

      Middle

               Last
      Client ID Number*:
       
      Client #
      Address: 
                                       Street
       
       City

      State

           Zip Code
      E-mail Address*:
      Reenter E-mail Address*:
      Telephone*:  Area Code
      Cell Phone:  Area Code
      Ok to Contact:
        Telephone
        Cell Phone
        E-mail
      Preferred Appointment Date and Time*:
      500 characters remaining
      Alternate Appointment Date and Time*:
      500 characters remaining
      Reason for Requesting an Appointment*:
      1500 characters remaining

      At busy times during the year, it is sometimes necessary for You Have a Friend Counseling Services to begin a waitlist in order to adequately serve those Clients already engaged in services through our office. Clients will be assessed through the intake process, but then may be placed on the waitlist or referred to other.

      Acknowledgements*

      I give consent for You Have a Friend Counseling Service to contact me regarding initiating services, understand that the service is not provided by a psychologist, social worker or other clinical professional, is based on educational and spiritual counseling principles and confirm that the information on this form is accurate to the best of my knowledge.