Appointment Request Form
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Today’s Date  *
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DD
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Which therapist would you like to be scheduled with?  *
Required
First and Last name of potential client *
May we text you with appointment updates? If so, please save our number 832-916-4416 *
Phone number *
Email addrsss *
Date of birth *
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DD
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*For couples clients only
First and Last name of partner/spouse AND email address
*If the potential client is a minor, please share the first and last name of the parent or care giver completing this form.
What brings you to therapy? Check all that apply *
Required
How did you hear about our practice? *
Required
What are you looking for in a therapist? *
Which day(s) work best for your therapy sessions? *
Required
Which time of day works best for your therapy sessions? *
Required
What type of therapy setting would you prefer? *
Please select an option for billing *
If you will bill your insurance, please select an option below
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Insurance Member ID 
Insurance Group ID
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