Western Wake Counseling & Psychological Services, PLLC

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Client Name (*)

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Date of Birth (*)

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Age

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Gender
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Contact Phone (*)

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Insurance Carrier

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Policy Number

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Legal Guardian (if applicable)

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Relationship with Client

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Referral Source and Contact (if applicable)

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Services Requested
Psychological Evaluation
Mental Health Assessment Individual Therapy/Counseling
Couple/Family Therapy
Group Therapy

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Briefly describe why you are seeking services

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Scheduling Preference/ Request/ Concerns

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