macaela gilson departure survey Your Name(Required) First Last Your Email(Required) Your Phone(Required)Disclosure Regarding Macaela's Departure and Attestation(Required) I attest that I am aware that Macaela Gilson will be leaving Change, Inc. and that her last day will be on 6/5/24.Statement of Intent Regarding Counseling // Desire Regarding Referral(Required)I intend to continue in counseling -- I would like to be referred to whichever Change, Inc. therapist Macaela has personally recommended for me!I'm not sure about continuing in counseling -- I would like a FREE meeting with Change, Inc.'s transition/triage team to help me decide.I intend to continue in counseling -- I would like to be referred to another therapist outside Change, Inc.I do not want a referral to another therapist.NOTE: Macaela will not be seeing Change, Inc. clients outside Change, Inc. auspices. i.e., Once Macaela leaves Change, Inc. she will not be able to continue seeing you. The menu gives you several options to choose from!Disclosure and Consent Regarding Discontinuing Counseling Services with Change, Inc.(Required) I attest that after my last session with Macaela Gilson, I will no longer be receiving counseling services from Change, Inc., and therefore will be discharged from their treatment environment. I understand that I may return to their treatment environment in the future, should I desire to do so and my treatment needs be compatible with their environment. I do currently hereby release Change, Inc. from any and all responsibility for my care.Request to be Contacted Regarding Referral/Transition(Required) I request that Change, Inc. contact me via email/phone in line with my Statement of Intent Regarding Counseling // Desire Regarding Referral statement above.CAPTCHA Δ
