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Libertas Counseling Inquiry Form
Please complete this form to request counseling services.
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Email
*
Your email
Full Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Town/City
*
Your answer
Phone number
*
Your answer
What services would you like to learn more about?
*
Individual Counseling
Couples/Marriage Counseling
Group Counseling
Telehealth Individual
Telehealth Couples/Marriage
Other:
Required
Will you be utilizing health insurance?
*
Yes
No
Other:
Please describe your best hopes for counseling? How would you like to live your best life?
*
Your answer
A copy of your responses will be emailed to the address you provided.
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