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Is there a particular Therapist you'd like to see? Or would you like to get an appointment ASAP? *
If you chose "Any Available", would you prefer the Riverton or Draper location? (ignore otherwise)
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To give our therapists some context why are you coming in? This can be as little or as much as you'd like to share. Example: Depression, Anxiety, Recent Divorce, Trauma. *
Date of Birth *
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Client Full Name *
Preferred name, if any.
Insurance Provider or Self Pay? We only take certain providers including but not limited to: Select Health, Regence Blue Cross Blue Shield, PEHP, Aetna. You can find more information about which providers we accept on our website. BestPracticeCounseling.com *
Cell phone number *
Email *
If you are the parent or guardian of the client please provide your name here.
Any other information you would like to let us know about?
How did you hear about us?
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