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Primary Contact Information:

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Participating Contact Information:

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Demographics:

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Referral Info:

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Why are you specifically seeking counseling?  (Check all that apply)

Mental Disorders:

Does anyone in your family (grandparents, parents, uncles, aunts, cousins, siblings, etc.) have an official diagnosis of a mental disorder?

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Are you taking any prescriptions medications?

Family Information:

Do you have children?

Ken-Lyn also offers “Associated Services.”  Are you seeking assistance with any of the following (Select  all that apply)?:

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