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Consent and Confidentiality Agreement
Thank you for trusting in me to support you and your family.
Kindly take a moment to fill out this form
before
our initial session together.
* Indicates required question
Email
*
Record my email address with my response
First and Last Name
*
Your answer
First and Last Name of other parent/guardian
*
Your answer
Best phone number(s) to quickly get into contact with you (if need be)
*
Your answer
Best e-mail to use to quickly get into contact with you
*
Your answer
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