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Amy Wine Counseling Center Appointment Request Form
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* Indicates required question
Email
*
Your email
First name
*
Your answer
Last name
*
Your answer
Phone number
*
Your answer
Do you have a specific therapist in mind?
*
Please visit the Meet Our Team page to get to know our counselors:
https://amywinecounseling.com/meet-our-team
Your answer
Do you have a preferred appointment day and/or time? Please check all that apply.
*
All new clients must come to the first appointment during the day. Our clinicians tend to have less availability on weeknights, as that is the most common request.
Monday
Tuesday
Wednesday
Thursday
Friday
8am to 12pm
12pm to 4pm
4pm to 8pm
No preference
Required
Interested in counseling for
*
Child (2-10 years old)
Preteen (11-13 years old)
Teen (14-17 years old)
Adult
Couples
Other:
Is there anything else you'd like your therapist to know?
Your answer
A copy of your responses will be emailed to the address you provided.
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