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THE PRACTICE
|
THE ACADEMY
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Psychiatric Services
Psychiatric Services Offered
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FAQ
Psychiatric Interest Form
Client's First Name
*
Client's Last Name
*
Client's Phone
*
Client's Email
*
Client's Date of Birth:
*
Guardian's FULL Name(s) and contact information, if client is under 18 y/o:
What type of appointment would you like to schedule? Choose all the apply
*
Individual Session
Family Sessions
Sessions for minor age 7-12
Sessions for minor age 13-17
Group Sessions
Session type:
*
In-person
Virtually
What insurance do you have?
File upload
Upload picture of Insurance Card
File upload
Upload picture of Photo ID
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