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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
The Girlfriend Chat
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
Last name
Date of Birth
*
required
Who referred you?
Which therapist do you prefer?
Choose a therapist
In-person or virtual session
*
In-person
Virtual (17 years of age and under must be in person)
Would you like spirituality incorpated into your therapy?
Where do you want therapy?
Choose a location
Which issues are you dealing with? (Check all that apply)
*
Required
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?
Continue
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