Intake Form

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Contact us

Telephone: 704-269-8548

E-mail: Emergetherapyllc@gmail.com

Name*

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Date of Birth*

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Address*

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City & State*

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Zip Code*

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Phone Number *

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Email Address*

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Emergency Contact Name and Number *

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What would you like to address in therapy?*

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EAP provider (Modern Health, Compsych, BHS, Curalinc, R3,)*

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* Indicates required fields

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Thank You for completing your intake form.

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