Counselling Intake Form
Please fill out this form to book an appointment with us.
I hereby give consent for evaluation and treatment. It is agreed that eitherof us may discontinue the evaluation and treatment at any time and that Iam free to accept or reject the treatment provided.
In the case of a minor child, I hereby affirm that I am a custodial parent or legal guardianof the child and that I authorize services for the child under the terms of this agreement.
I have read and understood the above and consent to these conditions for the counselling service provided by Bila Community Group.
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