Therapy Waitlist (opening in October)
Thank you for your inquiry regarding MotherlandCo., LLC services. Currently, we are not accepting new clients for therapy. However, if you wish to be considered on the waiting list please fill out the intake form.
Name (of person completing form) *
Email Address *
Phone Number *
Name of Client Referred *
Address *
City, State, ZIP Code *
Date of Birth *
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Type of Insurance *
Are you the policy holder? *
Phone Number of Insurance Plan (Please put N/A ONLY if uninsured or paying out of pocket) *
Insurance ID Number (Please put N/A ONLY if uninsured or paying out of pocket) *
Full Name of Policy Holder *
Policy Holder Date of Birth *
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Relationship to Policy Holder (ie: self, spouse, mother, etc)
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