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* 1. Email

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* 2. First and Last Name

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* 3. Preferred Name

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* 4. Date of Birth

Date

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* 5. Gender

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* 6. Preferred Pronouns

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* 7. City, State, Zip code

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* 8. Are you currently seeing a therapist?

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* 9. What type of insurance do you have?

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* 10. Please briefly describe why you're seeking therapy. Example: Anxiety, Trauma, PTSD, Depression, etc.

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