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Name
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Email
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Phone
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Do you prefer to be contacted by phone or email?
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Email
Phone
Do you have health insurance?
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If you have health insurance, what is the name of your health insurance company?
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Reason for Seeking Therapy (Examples: Depression, Anxiety, Grief, Relationship issues, etc.)
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Statement of emails and HIPAA Compliance
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I understand that email is not HIPPA compliant but will be used for basic communication regarding questions and ease of appointment scheduling.
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