Healing Reins EFP Mental Health Information
The information provided on this form is to assist our office in directing you toward the therapist that is the best fit.
Name *
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Age *
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Gender *
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Insurance:
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Reason for seeking counseling:
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Are you willing and able to pay out of pocket for EFP services?
Tell us your availability for a weekly session:
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Phone:
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Email: *
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Date: *
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