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Name*

First Last

Email*

Phone*

Age of person seeking therapy?*

This information assists in selecting the appropriate practitioner.

Is the client in school?

Which school is the client attending?

Will you be using insurance?

What Insurance Company?

Brief reason for seeking services:

Please give only a general description.
Do not send sensitive details over email.

Are you flexible in regards to scheduling?

Other scheduling needs or preferences?

Additional information you would like us to know?

Vaccination Status*

* Fully vaccinated means you are 14 days past your second dose of Moderna or Pfizer or 14 days past a Johnson and Johnson single dose.

I will be fully vaccinated on*

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