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Is your child interested in getting help? (Please know that unless your child is willing to get help, there is not much that I can offer.) *


 
What's your first name? *

 
How old is your child? *

 
What is your child's biggest problem currently? *

 
How have you and your child tried to fix this problem in the past? *

 
What results are you looking for? *

 
Is there anything else you would like me to know? *

 
What is your phone number? *

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