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Client Information

Please fill up this signup form as best as you can to help us serve you better.

Pronouns
What is your work/profession?
Relation to Emergency Contact:

Please provide the number of your emergency contact. This person will only be contacted in an emergency.

Reasons for seeking help
How intense is your emotional distress?
To what degree do your problems affect your ability to perform at work, at home, and in your relationships with others?
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