Name *

First Name

Last Name

Phone

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Do you live in California? *

Yes

No

No, but I am moving there soon

What are you interested in? *

Select all that apply

Individual Therapy

Group Therapy

Presentation or Workshop

Something not listed (please elaborate below)

Acknowledgement *

I understand that this form is not a confidential communication.

I will not include any sensitive material, nor use this form for emergencies.

I understand that no professional relationship has been established by using this form.