You must have JavaScript enabled to use this form. First Name Last Name Who is your Counselor, please? - Select -Lance Clark, MA, LCMHC, BC-TMH, QSNicole Mooney, MA, LCMHCA, NCCLauren Caulberg, MA, LCMHCA, NCCPlease put me on Will McRee's WAIT LIST CONFIDENTIALITY STATEMENT Please know that we are MANDATED BY LAW, as professional counselors, to report any threat of harm to self or others, or child or elder or disabled persons abuse/neglect. We CANNOT guarantee confidentiality if you disclose such issues via this form. Have you experienced suicidal thinking in the past 72 hours (3 days)? Yes No Have you harmed yourself in the past 72 hours (3 days)? Yes No Have you abused any prescription drug, street drug, or alcohol in the past 72 hours (3 days)? Yes No Would you say that your PRIMARY presenting issue is Anxiety? Yes No SUBMIT Leave this field blank
