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* 1. I am scheduling an appointment for an emergency situation?

If this is an emergency, please call 911.

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* 2. Patient's Information Below

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* 3. Enter the insurance policy holder's information here (self, parent, spouse):

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* 4. Enter the Insurance information here (if you have a secondary insurance, just enter Primary Policy below):

You can view our therapist's profiles on the "About Us" page of our website at www.PersonalSolutionsCounseling.com.

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* 5. Please select which therapists you would prefer to work with:

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* 6. Please select one option below:

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* 7. What days of the week and times of the day are best for you?

  Mon Tue Wed Thu Fri Sat
9 am to Noon
Noon to 4 pm
4 pm to 9 pm
Anytime
Thank you for completing this questionnaire. We will be in touch asap.

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