Along Your Journey, PLLC | SimplePractice

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Administrative

Inquiry reason

Client Preferences

Preferred clinician

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Preferred modality

(all clients are hybrid however, we need to know what you will use more)

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

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If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

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