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NOTE
: I am only working with US-based clients at this time.
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I am a US resident
I am an international resident
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Full Name
*
Your answer
Phone Number
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Your answer
Email Address
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Your answer
Where are you located? (city & state)
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Your answer
Preferred day & time for therapy (select all that apply)
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Monday
Tuesday
Wednesday
Thursday
Mid-day (11am - 3pm)
Late afternoon (3pm - 5pm)
Evening (5pm - 7pm)
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What brings you to therapy?
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Your answer
Who referred you?
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Your answer
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