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Initial Application
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Email
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Your email
Client Full
Name
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Your answer
Parent/Legal Guardian (if under 18):
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Email:
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Note: email correspondence is not considered to be a confidential form of communication.)
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Your answer
Phone Number :
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May I leave a message?
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Address:
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Date of Birth:
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What is the reason(s) you are seeking my services?
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Your answer
What would you like to accomplish during your time in therapy?
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