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Community Care Fund waitlist
Please complete this form to be notified when funding is available to cover a requested session.
Thank you!
Take care,
Lesley
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Gender
*
Your answer
Pronouns
*
Your answer
Phone number
*
Your answer
Session length requested
*
30 minutes
60 minutes
90 minutes
Any questions or additional information you'd like me to know? (This does not replace the intake form which must be completed prior to a session.)
Your answer
A copy of your responses will be emailed to the address you provided.
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