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Must Complete: Informed Consent Form
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Dr. Sparrow's DreamStar Counseling and Supervision Services
Supporting Your Courage to Heal and to Grow
Fill in the form below to send me an email.
Your Name
*
Your Email
*
Phone Number
*
Date of Birth
*
Address
*
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)
Primary Care Physician
Is the client covered by insurance?
*
If so, please provide the insurance company:
Policyholder/Subscriber's name
Policyholder/Subscriber's ID#
Policyholder/Subscriber's DOB
Insurance Group Number
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