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New Patient Information Form
Preferred email address
Please briefly state the reason you are seeking therapy services (i.e.: depression, anxiety, etc)
Were you referred to my office by anyone? If yes, may I ask who?
Do you plan on using health insurance for sessions?
If yes, which plan / company do you have?
Do any of the following apply to you?
I am currently seeing a psychiatrist.
I have been hospitalized in the past.
I am interested in individual therapy.
I am interested in couples therapy.
I am interested in family therapy.
I am interested in services for my teenager.
I have had outpatient therapy in the past.
Business Fax: 866-542-5768
(State Farm Building)
12001 West Parmer Lane, Ste. 200
Cedar Park, TX 78613
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