Intake Screener - Anxiety Therapy LA
Date *
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Name *
Your answer
Best phone number to reach you or client *
Your answer
Email Address
Your answer
Calling for:
Name of client if not calling for self
Your answer
Client age *
Your answer
Client location
Your answer
Preferred office location *
Primary condition *
Required
Previous Therapy
Primarily interested in: *
Therapist preference: *
Preferred day of the week (Check all that apply) *
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Preferred time of day (Check all that apply) *
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How did you hear about us?
Please note, we are out of network with all insurance companies. We can provide a superbill for you to get reimbursement from your insurance company. Payment is required at time of treatment. *
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