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Sliding-Scale Waitlist Form
DISCLAIMER:
My practice has a limited number of sliding scale spots, which are currently full. Submission of waitlist form does not guarantee appointment availability.
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* Indicates required question
Name
Your answer
Email
Your answer
Phone Number
Your answer
Today's Date
MM
/
DD
/
YYYY
What type of service(s) are you seeking?
Individual Therapy
Family Therapy
Group Therapy
Other:
Annual household income
Your answer
Household size
Your answer
I understand that this submission form does not guarantee an appointment.
*
Yes
Required
I consent to receiving an email/phone call/text message when sliding scale appointments are available.
*
Yes
Required
What is your preferred method of communication?
*
Email
Phone call
Text message
Required
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