Rewired Canvas - Scheduling Form
Please complete the form to initiate services or to receive information.
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Email *
Name  *
Phone number
Option for text messaging as an additional contact method. It is not mandatory to provide a mobile number. In the event you wish to communicate about scheduling or to receive telehealth links via text please indicate your choice:

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What services are you seeking and how can I help you? *
Are you inquiring about services for yourself or someone else? (If inquiring about others, please provide their name). For yourself and/or others, please include date(s) of birth.  *
What insurance do you have? Or do you prefer direct pay? *
Have you ever had counseling before?
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Are you currently taking medications or working with another mental health provider?
Do you have any specific preferences or requirements for therapy?
Any issues with transportation or mobility?
Do you have any pressing medical or legal concerns currently? *
What are your preferences for appt day / time? List any known conflicts also. 
How did you hear about me?
What questions do you have or other information you'd like to provide?
Thank you for your inquiry. 
We will do our best to get back to you by phone within 48 hours. Feel free to email info@rewiredcanvas.com if you would like to follow up or have additional questions. 
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