Brown Sugar Clinicians Therapist Request

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1. Client Information

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2. In your own words, please briefly describe why you are seeking services today.

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3. Have you previously received therapy or mental health treatment?

No

Yes- Briefly describe type of treatment and approximate date

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4. What are your primary goals for therapy? Check all that apply:

Manage Anxienty

Cope with Trauma

Substance Abuse

Manage Depression

Work/Life Stress

Self- Esteem

Greif and Loss

Other (please specify)