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Counseling Inquiry Form
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Email *
First Name *
Last Name *
Date of birth *
MM
/
DD
/
YYYY
Email *
Phone number (###-###-####) *
Please tell us in a a few words; What brings you to counseling and Who will be participating in the sessions (self, couple, family, kids). *
What type of therapy are you interested in? (check all that apply) *
Required
Therapist you'd like to work with
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Appointment time preference; Day and Time (Office hours are M-F 8am to 6pm; Some Therapists have availability outside these hours) *
Therapy Location Preference *
Please let us know if you are wanting to use insurance, by selecting one of the participating providers below. *
If we are not in Network with your insurance provider, are you interested in private pay? (we can provide a superbill for you to submit for out of network) *
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