COVID-19 Safety Measures
Social Media Policy Statement
Patient Information Form
Informed Consent and Procedures
Cross Cutting of Symptoms Intake Survey
Directions to the Office
Fees and Prepayments
Teaching and Training
Dr. Sparrow's Counseling Services
Supporting Your Courage to Heal and to Grow
© 2020 Dr. G. Scott Sparrow
Fill in the form below to send me an email.
Date of Birth
City, State, Zip
Father's name if client is a minor
Father's DOB if client is a minor
Mother's name if client is a minor
Mother's DOB is client is a minor
Has the client been in psychoterapeutic or psychiatric care?
If so, please provide the therapist's/doctor's name(s)
Is the client covered by insurance?
If so, please provide the insurance company:
Insurance Group Number
Spam Protection: Please don't fill this in: