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Waiting List Referral for Absolute Minds
Please fill out as much detail as possible. Self or Third party referrals accepted.
This is for waiting list only, Nadine will contact you to discuss your referral.
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Email
*
Your email
Todays Date
*
MM
/
DD
/
YYYY
Name of participant for waiting list
*
Your answer
Age of Participant
*
Your answer
Town participant lives
Your answer
Reasons for seeking therapy. Please include current challenges and any known diagnosis
*
Your answer
Contact details for participant and/or repesentintive. Please include name, phone number and email address.
*
Your answer
If not self referred, please state name and relationship to participant.
Your answer
Would you like Absolute Minds to contact you about your referral?
*
Yes please
No thank you.
Would the Participant like to be on my casual session list?
Occasionally, there cancellations and I offer these sessions to people on my casual list.
*
Yes
No
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