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Family Wellness & Support Services Form

Personal and Family Information

Multi-line address

Health and Wellness Information

Goals for Participation

Preferred Services and Support

Previous Support or Services Used

Consent and Confidentiality

Consent for counseling or group participation (required for minors, parental/guardian consent for children)
Consent
No Consent
Confidentiality agreement to ensure privacy during counseling or group sessions
Consent
No Consent

Emergency Needs and Crisis Support

Follow-Up and Ongoing Support Preferences

Preferred method of communication for updates and follow-ups

Commitment to Participation

Willingness to attend all scheduled sessions and actively participate in the program
Yes
No
Agreement to provide feedback for program evaluation and improvement
Yes
No
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