Follow-up Contact Information
Please complete our priority contact form and our team will reach out to you when appointments become available. Thank you!
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Email *
Phone Number *
Full Name *
Date of Birth of client: *
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It would help us to know how flexible your availability is for sessions. Please indicate your preferences below: *
Do we have permission to text you regarding immediate openings? *
What are you seeking? *
General therapy needs? *
Preferred Location *
Type of Insurance
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Member ID#
Thank you for taking the time to connect with us through this Google Form.
We realize that reaching out for support is not always easy. Please know that we appreciate you taking the time fill out the above form so that we can attempt to connect with you services soon. Our goal is to connect clients with the best fit therapist to provide a space where healing can take place.
A copy of your responses will be emailed to the address you provided.
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