New Client Interest Form

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Thanks for your interest in working with me. Please answer the questions below so I can assist you in the best way. If you are struggling with this form, you can email me directly at stephanie@seattlequeertherapy.com. Please allow 1-2 business days for a response. I look forward to speaking with you.

Legal Name *

Preferred Name *

Email *

Preferred Pronouns *

Are you the primary client? If not, what's your relationship? i.e. parent *

Date of Birth (of primary client) *

YYYY

Best phone number to reach you at? *

Do we have permission to leave a detailed message and the phone or email you've provided regarding your request? *

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