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Welcome_and_Intake

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									              Judith-ann Anderson, M.Ed. Licensed Professional Counselor
            LPC Approved Supervisor, Certified Anger Resolution Therapist
                            Employee Assistance Provider
                  2727 Duval Drive, Dallas, Tx 75211; 214-337-7288
                               andehere4u@gmail.com


                       Welcome and Intake Information

Name___________________________________________
     First              Middle           Last
Address_______________________________________
          (City/St/Zip)
Phone Numbers ______________________________________
                Home            Cell                  Office
Email address_____________________________________
DOB_______________________________________________
Job title__________________________________________
Company_________________________________________
Name of Benefit EAP and/or Insurance/Cert no or ins id #
________________________________________________

Statement of Confidentiality:
I understand all things stated in therapy remain confidential except for
these reasons: 1) If I reveal I want to harm myself or someone else 2)I
reveal abuse going on right now. 3) If counselor is subpoenaed by a court of
law.

Agreement to 24 hour notice: I agree to contact counselor
24 hours before cancellation. If I fail to notify before 24
hours, I agree to pay $25 to reinstate my case with this
counselor before therapy can be continued.

_________________________________________________________
Name (Signature)                      Date

I agree to accept emails and/or newsletters from Judith Ann Anderson.
Yes or no ( circle answer)

								
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