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Therapeutic Services Request

This form is for individuals or families seeking licensed therapeutic services, including individual therapy or clinician-led therapeutic groups. Submitting this form does not establish a therapeutic relationship.

Birthday
Day
Month
Year
Preferred Method of Contact
Phone
Email
Services of Interest (Select all that apply)
Individual therapy
Therapeutic group services
Availability
Preferred days/times
In-person or virtual (if applicable)
Insurance / Payment
Self-pay
Insurance (if applicable – verification required)
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