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2021 Couples' Vision Board Series Registration
Thank you for your interest in the Couples' Vision Board Series with Nishia Livingston, LPC! She looks forward to supporting you! Please take time to respond to each item.
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Are you married, preparing for marriage or dating?
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Married
Preparing for marriage
Dating
How long have you been a couple?
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Your answer
Significant Other 1: First and Last name
*
Your answer
Best email to reach you. (Please provide separate email)
*
Your answer
Best phone number to reach you. (Please provide separate number)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Significant Other 2: First and Last name
*
Your answer
Best email to reach you. (Please provide separate email)
*
Your answer
Best phone number to reach you. (Please provide separate number)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
After completing this form, a secure link from Simple Practice will be sent to you for payment and consultation login details.
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