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Date of Birth

Sex

Phone

Email

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Will you be Paying Cash?

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Group ID

Address

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What time of day works best for your Appointment?

12:00PM-03:00PM
03:00PM-05:00PM
05:00PM-07:00PM

Reason for Visit?

ADD/ADHD
Addiction/Substance Abuse
Anxiety
Bipolar Disorder
Depression
Panic Disorder
Prescription/Refill
Post-traumatic stress disorder (PTSD)
Stress
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