General Information Your Name(required) Address(required) City(required) State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY (required) Zip code(required) Phone - Home(required) Phone - Cell(required) Phone - Work(required) Fax Email(valid email required) Please Repeat Email(valid email required) Marital Status Single Married Separated Divorced Widowed If married, how many years? If divorced, how many years? Have you ever been in counseling? If yes when? Are you now in counseling? If yes how long? With whom are you counseling? If you were referred, by whom? Briefly describe what you would like to accomplish in counseling: Briefly describe your original family Do you regularly use legal or illegal medications? Alcohol? Describe By my signature below, I agree that I am committed to coming and working on my individual issues. Also, I understand that it is required that I not bring other family members with me to this appointment unless it is suggested by LFEM or I am a parent coming with my child/teen. Input your full name to sign this form Signature Date cforms contact form by delicious:days
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