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New Client Appointment Request
Doylestown Counseling Associates, Inc.
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Name
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Phone Number
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Can we text you?
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No
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Email Address
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Briefly, why would you like to schedule an appointment? What services are you interested in? (ie., anxiety, relationship/family issues, grief, depression, work issues, couples etc)
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I prefer
In Person
Telehealth
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Have you been hospitalized for any mental health issues within the last 6 months?
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Age
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Date of Birth
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Health Insurance Coverage
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Medicare Part B
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Aetna
Allied Trades
Amerihealth
Blue Cross - Anthem
Blue Cross - Horizon
Blue Cross - Independence Administrators
Blue Cross - Keystone East
Blue Cross - Personal Choice
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Cigna
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