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Waiting List

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* First Name
* Last Name
Name of partner(s) (if couples counseling)
* Phone
Partner(s) Phone(s) (if couples counseling)
* E-mail(s)
* How did you hear about us? 
* Payment Method (select one - we are out of network for all other insurance plans)
Birth Date (client)
BCBS Member ID # (if applicable)
    Please provide us with your BCBS member ID number and date of birth if you would like us to verfiy your insurance for you.
Insurance Policy Subscriber Full Name (if applicable)
What is the insurance policy subscriber's relationship to the client? (if applicable)
Gender (if using insurance)
    If you would like to use this system to manage your future appointments, please create a username and password.
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Waiting List Information

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