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Attachment & Dissociation Evaluation
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Participant Full Name
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Mailing Address
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Email Address
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License Type (profession/discipline, e.g., psychologist,counselor, etc.)
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Licensed Psychologist
LCSW-- Social Worker
MFT-- Marriage and Family Counselor
CD-- Chemical Dependency Counselor
Licensed Professional Counselor
Psychiatrist or other MD
Student/Intern
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License number & State
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