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ALCC Interest Form
Thank you for your interest in Another Level Counseling and Consultation. Please complete this form if you are interested in any of our services or would like to refer someone for services. We will respond to your submission within 48 hours. Thank you!!!
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Email
*
Your email
Referral Name, Email, Phone (type N/A if not applicable):
*
Your answer
First and Last Name of the Person Seeking Services
*
Your answer
Parent/Legal Guardian if Person Seeking Services is under 18 years old (Type N/A if not applicable)
Your answer
Phone Number:
*
Your answer
Email Address:
Your answer
I am requesting the following services (check all that apply):
*
Consultation (Private Practice/Business)
Couples Counseling Services
Family Counseling Services
Individual Counseling Services
Training
Optic Oasis - Virtual Reality Wellness Lounge
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Any additional information you would like to share?
Your answer
For counseling services, please identify how you plan to pay for services below so we can pair you with a provider:
Blue Cross Blue Shield
Healthy Blue Medicaid
Aetna
Cigna
Private pay - out of pocket
Sliding scale services needed
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A copy of your responses will be emailed to the address you provided.
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