What Service or Services are you interested in? *

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Individual Therapy

Couples Therapy

Family Therapy

EMDR Therapy

Medications (must have therapist with us)

Life Coaching

Client's Name *

First Name

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Date of Birth *

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Pay Source: (Please Check All That Apply) *

Medicaid

Private Insurance

Self Pay

Need Sliding Fee Scale

EAP (employer)

EmpowHERment

CASA

Inner Truth Project

Drug Court

Child Welfare

CFBHN

PSL School Board

Martin School Board