Request Appointment
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Email *
Name *
Phone
Type of Therapy Requested *
Required
Session Format or Location
Weekday Appointment Availability
Morning
Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Friday & Weekend Appointment Availability
Morning
Afternoon
Friday
Saturday
Sunday
Do you have private insurance coverage?
If yes, which professional providers are covered under your insurance? Please note we do NOT have psychologists at our clinic! Check your insurance for the the registration title e.g. psychotherapist, not descriptive terms like psychotherapy.
Would you prefer a therapist with (check all that apply):
A copy of your responses will be emailed to the address you provided.
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