Counselor Jane Smith

About Me

Transform Your Business with Cutting-Edge Tech Solutions BITBIZ NIG LIMITED delivers innovative software, web, and mobile solutions that drive growth. From concept to deployment, we build technology that works for your business.

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Client Intake Form

Email

Full Name

Date of Birth

Gender

Phone Number (WhatsApp)

Location

Emergency Contact

Name

Relationship to You

Phone Number

General Health Information

Reasons for Seeking Counseling

Current Symptoms or Challenges

Have you ever attended counseling or therapy before?

If yes, please provide details

Guardian's Approval (For Clients Under 18 years)

Guardian's Consent

I, hereby consent to my ward participating in counseling services provided by Blaze Health Foundation. I acknowledge that I am authorized to make decisions on behalf of and will be responsible for their attendance and participation in counseling sessions.

Valid ID Card (If over 18)

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