Let's Talk

Please enter your full name.
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Optional: Provide your phone number for contact.
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How would you prefer to be contacted?
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Please describe the main reasons you are seeking therapy.
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Please list any medications you are currently taking, including dosage.
Have you previously attended therapy?
Select yes or no if you have attended therapy before.
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Please provide the name of an emergency contact person.
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Provide the phone number of your emergency contact.
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Preferred Therapy Format
Which therapy format do you prefer?
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Please describe your availability for therapy sessions.
Feel free to share any additional information that may be helpful.
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