Socially 7 Individual Therapy Intake Form
Thank you for completing the following information. 
Email *
Therapy Participant Name
First and last name
Participant DOB
MM
/
DD
/
YYYY
Parent/Conservator Name: 
Parent/Conservator Mailing Address
Parent/Conservator Email
Parent/Conservator Phone number
What service are you interested in?
Individual Therapy is $100/Hour ($50/30 minutes) & can be made via cash, check, credit card or Venmo.

At this time I am not able to accept insurance but I will provide an invoice/report that you can submit to insurance if you choose to do so. 

I will bill you at the end of every month and I ask that bills are paid within 2 weeks. 
Do you have any specific days/time that you prefer therapy take place? 
Is there any additional information you want me to know? 
Thank you for taking the time to complete this Intake Form. 
I will be in touch soon!

Micki
#865-221-7537
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