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