Waitlist for Simply Mindful Counseling
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Email *
Patient Name (First and Last) *
Patient Date of Birth *
MM
/
DD
/
YYYY
If Patient is a Minor, Guardian's Name (First and Last)
Preferred Method of Contact *
Required
Preferred phone number: *
Preferred email address? *
What is the main reason you are seeking therapy? *
Health Insurance?
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Is there a clinician you would prefer to work with? (Check all that apply)
Preferred appointment time? (Check all that apply.)
Monday
Tuesday
Wednesday
Thursday
Friday
Weekend
Daytime availability (9AM to 4PM)
Evening availability (4PM to 9PM)
Thank you! We will contact you as soon as a session that fits your request is available.
A copy of your responses will be emailed to the address you provided.
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