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Client Intake Form

Birthday
Month
Day
Year

-1:1 Counseling \ Support

-Group Counseling

-Grief Counseling

-Workshops

-Corporate \ Facility Programming

-Other

Please share what brings you here and what you hope to gain from our services.

Please list any current health concerns, medications, or diagnoses we should be aware of to best support you.

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I understand that the services offered by The Phoenix Enhancing The Spirit LLC are for educational and support purposes and are not a substitute for medical or psychological treatment. I consent to participate and understand that I may withdraw at any time.

Date
Month
Day
Year

Thank you for your interest in our safe space. Please give us 1-2 business days to respond. We thank you for your patience.

© 2021- Website Created by KhepeRa Alyce|2021- Website Designed by Ebony Sharrieff

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