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Socially 7 Individual Therapy Intake Form
Thank you for completing the following information.
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Email
*
Record my email address with my response
Therapy Participant Name
First and last name
Your answer
Participant DOB
MM
/
DD
/
YYYY
Parent/Conservator Name:
Your answer
Parent/Conservator Mailing Address
Your answer
Parent/Conservator Email
Your answer
Parent/Conservator Phone number
Your answer
What service are you interested in?
Individual Therapy
Social Skills Groups
Other:
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.
I understand & agree to this.
I would like to talk about the possibility of other arrangements.
Do you have any specific days/time that you prefer therapy take place?
Your answer
Is there any additional information you want me to know?
Your answer
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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