Client Application Form
Please fill out the following quesitons in order to submit your application to be a client of Dr. Waleszonia and/or Dr. Whyte
Email *
Name *
First and last name
Date of Birth *
MM
/
DD
/
YYYY
Phone number *
What service are you interested in? *
Required
What are you wanting to work on at this time?  *
Are you willing to put in the work to see results? *
If you've participated in therapy before, please provide a brief account of when and what for, as well as the outcome. 
Do you have any medical or psychological diagnoses? If so, please list them below. 
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