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HUMMINGBIRD COUNSELING
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Home
Services
Policy
Forms
Referral Form
Lyra Referral Form
Client Feedback Form
Employee Time Off Request Form
Contact Us
Groups
Finding Me Group Session
Referral Form
Please take the time to fill out the information below.
First name
Email
Middle Name
Phone
Address (include City, State, and Zip Code
Which therapist do you prefer?
Choose a therapist
Would you like spirituality incorpated into your therapy?
Last name
Date of Birth
Who referred you?
In-person or virtual session
*
In-person
Virtual
Where do you want therapy?
Choose a location
Which issues are you dealing with? (Check all that apply)
Anxiety
Depression
Grief
PTSD
Trauma
Substance Abuse
Adjustment Issues
Anger
Chronic Health Issues
Family or Work Stress
Relationship Problems
Self Esteem Issues
What has happened that brings you to therapy?
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