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Brief Questionnaire
Name
*
Email
*
Phone
*
Permission to text additional information.
Insurance or Self-Pay?
*
If using insurance, which network?
Coaching or Therapy?
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Coaching ($125) is self-pay - no diagnosis.
Expectations Regarding Services
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How will you benefit - what will be different?
Preferred Meeting Day(s) & Time(s)
*
List a couple of preferences or N/A.
Anything else you want me to know?
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