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Balance Therapy Center of Ventura County
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Intake form
Help us serve you better
Name
*
Email address
*
What type of therapy are you interested in?
Please select at least one option.
Family Therapy
Private Mediation
Co-Parenting Therapy
What are the main issues you wish to address?
How many family members will participate in the therapy?
Select
1
2
3
4
5 or more
What is your preferred method of communication?
Select
Phone
Email
Video Call
Are you currently involved in any family court cases?
Select
Yes
No
If yes, please provide details about the case.
Have you previously engaged in therapy?
Select
Yes
No
If yes, please describe your previous therapy experience.
Which service or services are you interested in?
Please select at least one option.
Individual therapy
Private mediation
Co-parenting therapy
Reunification therapy
Additional questions or comments
Submit
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