What is the primary reason you’re seeking counseling services?
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Family conflicts
Marital or relationship issues
Parenting challenges
Personal mental health concerns
Other
Which type of counseling are you interested in?
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Individual therapy
Couples therapy
Family therapy
Group therapy
Not sure yet
Have you previously participated in counseling or therapy?
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Yes, within the past year
Yes, over a year ago
No, this is my first time
Prefer not to say
How comfortable are you with teletherapy (online counseling sessions)?
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Very comfortable
Somewhat comfortable
Not comfortable
Unsure, need more information
When are you generally available for sessions?
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Weekday mornings
Weekday afternoons
Weekday evenings
Weekends
Flexible
What is your preferred method of communication for scheduling and reminders?
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Phone call
Text message
Email
No preference
Do you have a preference for the therapist’s gender?
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Prefer a female therapist
Prefer a male therapist
No preference
Prefer not to say
Are you currently experiencing any of the following?
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Anxiety or excessive worry
Depression or persistent sadness
Stress related to a life change
None of the above
Prefer not to say
How did you hear about ACT Family Counseling?
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Online search
Social media
Referral from a friend or family member
Referred by a healthcare provider
Other
What are your goals for counseling?
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Improve communication within the family
Resolve specific conflicts
Develop coping strategies
Personal growth and self-understanding
Other
First Name
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Last Name
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Phone
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Email
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