NADIIA PETRENKO DEPARTURE SURVEY Your Name(Required) First Last Your Email(Required) Your Phone(Required)Disclosure Regarding Nadiia Petrenko's Departure and Attestation(Required) I attest that I am aware that Nadiia Petrenko will be leaving Change, Inc., and her last day will be on 8/12/23.Statement of Intention(Required)I would like to continue seeing her outside Change, lnc.I would like to discontinue seeing her.Desire Regarding A New Therapist(Required)I would like to be referred to another therapist at or 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 Nadiia Petrenko(Required) I attest that I am aware that after 8/12/23, 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 Nadiia Petrenko will become responsible for my treatment in its entirety henceforth and do hereby release Change, Inc. from any and all responsibility for my care.Disclosure and Consent Regarding Discontinuing Counseling Services with Change, Inc.(Required) I attest that I am aware that after my last session with Nadiia Petrenko, 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
