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Intake form
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Under 18
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35-44
45-54
55-64
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What is your primary diagnosis?
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Anxiety
Bipolar Disorder
Depression
Schizophrenia
Autism Spectrum Disorder
Post-Traumatic Stress Disorder (PTSD)
What services are you interested in?
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Counseling
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Case Management
Social Skills Training
Employment Services
Crisis Intervention
Do you have any specific needs or accommodations?
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Are you currently receiving treatment or support?
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How did you hear about hedwig house?
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Which service or services are you interested in?
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