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Appointment Request Form
Please provide the following information to help determine if Markle Professional Counseling is the best provider to meet your needs. Dr. Markle will review your responses and will typically respond within 1-2 business days.
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Full Legal Name:
*
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
Phone Number:
*
Your answer
Email:
*
Your answer
Address:
Your answer
Preferred method to contact you:
*
Phone Call
Text Message
Email
Other:
What is the primary reason you are seeking services?
*
Your answer
Are you aware that all services are being conducted online and not in person at the present time?
*
Yes
No
Are you aware that Markle Professional Counseling is self pay and considered out of network for all insurance companies?
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Yes
No
What is your current availability for therapy appointments?
*
Weekday mornings
Weekday afternoons
Weekday evenings
Weekends
Other:
Required
Do you have any questions? Any additional information you would like to provide?
Your answer
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