Christina Diesen, LCSW
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  • Counseling & Therapy
  • Classes & Events
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  • New Client Forms
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ASRC.com
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Christina Diesen, LCSW
Home
Services
  • Counseling & Therapy
  • Classes & Events
About
  • Modalities & Approach
  • My Story
Contact
Resources
  • New Client Forms
  • Client Resources
  • Resources for Everyone
ASRC.com
Audio
More
  • Home
  • Services
    • Counseling & Therapy
    • Classes & Events
  • About
    • Modalities & Approach
    • My Story
  • Contact
  • Resources
    • New Client Forms
    • Client Resources
    • Resources for Everyone
  • ASRC.com
  • Audio
  • Home
  • Services
    • Counseling & Therapy
    • Classes & Events
  • About
    • Modalities & Approach
    • My Story
  • Contact
  • Resources
    • New Client Forms
    • Client Resources
    • Resources for Everyone
  • ASRC.com
  • Audio

New Client Intake Forms

Once you have been in contact with our offcie and have established an upcoming appointment, 


Review, complete and return the Intake Paperwork before your first appointment. 


Either bring the completed forms with you to your appointment. If meeting in person  


or if meeting online for Telehealth, return the Intake Paperwork 

at least 2 days before your first appointment by faxing them to us at 618-227-8227 


An electronic option is currently being developed and will be available soon.

Intake Paperwork for New Clients. Please print, complete and return in person or via fax @ 618-227-8 (pdf)

Download

READ ONLY Privacy Practice Notice: FYI Only (ASRC). Your signature for agreement is on the last page (pdf)

Download

After contacting our office & having a set appointment

Arrive at our office at the time of your scheduled appointment,.  If meeting in person bring your completed paperwork with you to meet in person at 110 North Main Street in Brreese, IL 62230


OR


If choosing Telehealth,  fax your completed paperwork at least 2 days before your scheduled appointment to 618-227-8227 and follow our instruction to access Telehealth services 


We look forward to getting to know and assist you! 

Copyright © 2015- 2026 Christina Diesen, LCSW, Education, Speaking & Therapy Services - All Rights Reserved.

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