Client First Name
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Client Last Name
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Date of birth
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Person Filling out form
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Relationship to the client
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Self (I am the client)
Legal Guardian, Caregiver, Parent
Caseworker or Social Worker
Medical Provider
Email
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Phone
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Acknowledgement of fee
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I understand that group costs $50/session
Please describe why you are interested in a group.
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Messaging Consent
By providing your phone number, you agree to receive text messages from Step By Step Counseling. Message and data rates may apply. Message frequency varies. Reply STOP to opt out.
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