MatT ANDERSON departure survey Your Name(Required) First Last Your Email(Required) Your Phone(Required)Disclosure Regarding Matt Anderson's Departure and Attestation(Required) I attest that I am aware that Matt Anderson will be leaving Change, Inc., and his last day will be on 12/30/25.Statement of Intent(Required)I would like to continue seeing Matt outside Change, lnc.I would like to discontinue seeing Matt.Desire Regarding A New Therapist(Required)I intend to continue in counseling -- I would like a FREE SESSION with another Change, Inc. therapist!I'm not sure about continuing in counseling -- I would a FREE SESSION with Change, Inc.'s transition/triage team to help me decide whether to continue and with whom!I intend to continue in counseling -- I would like to be referred to another therapist outside Change, Inc.I do not need a referral to another therapist.Disclosure and Consent Regarding Discontinuing Counseling Services with Change, Inc. and Transferring to Matt Anderson(Required) I attest that I am aware that after 12/30/25, 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 understand that Matt Anderson will become solely responsible for my treatment in its entirety henceforth and do hereby release Change, Inc. from any and all responsibility for my care effective 12/30/25.Disclosure and Consent Regarding Discontinuing Counseling Services with Change, Inc.(Required) I attest that I am aware that after my last session with Matt Anderson, 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
