Intake Information Form

This form is used to collect basic information about you and your insurance provider.

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  • Deirdre F. Haynes, Ed.S, NBCT, NCC, LPCS, GCDF
    1030 St. Andrews Road, Suite A-1 Columbia, SC 29210
    Phone: 803-790-2025   Fax: 803-790-7010
    E-mail: dhaynes@dhaynestherapy.com
    Website: http://dhaynestherapy.com
    Licensed Professional Counselor (#5425), State of South Carolina

  • Intake Information:

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