INTAKE FORMS

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Adults

Children

Full Name
Email
Please briefly describe the issue you are having.
Phone Number
Address
City
State
Zip Code
Relationship
Today's Date
Birthdate
Emergency Contact
Phone Number
Marital Status
I have read/agree to the HIPAA below. (Y/N)
Short Text
May we contact you via text? (Y/N)
If "Yes", Who is your cell phone carrier?
How Did You Hear About EWCC?
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Child's Full Name
Email
Please briefly describe the issue you are having.
Phone Number
Address
City
State
Zip Code
Parent's name(s)
Today's Date
Birthdate
Emergency Contact
Relationship
Phone Number
I have read/agree to the HIPAA below. (Y/N)
Is there a parenting plan in place? (Y/N)
If, "Yes" who has decision-making rights?
May we contact you via text? (Y/N)
If "Yes", who is your cell phone carrier?
How Did You Hear About EWCC?
Submit
HIPAA Notice Form