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Horizon Wellness Group LLC
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Intake form
Help us serve you better
Name
*
Email address
*
What services are you interested in?
Please select at least one option.
Outpatient therapy
Counseling
Psychiatric medication management
Supportive living services
Transgender services
What is your preferred method of communication?
Select
Phone
Email
Text message
Do you have any specific goals for therapy or counseling?
Have you previously received any mental health services? if yes, please specify.
What is your age group?
Select
Under 18
18-24
25-34
35-44
45-54
55-64
65 and above
Do you have any relevant medical history we should be aware of?
What is your preferred appointment time?
Select
Morning
Afternoon
Evening
Are you currently taking any medications? if yes, please list them.
What is your preferred language for communication?
Select
English
Spanish
How did you hear about us?
Select
Referral
Online search
Social media
Additional questions or comments
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