Request an Appointment - New Clients
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First Name: *
Last Name: *
Birthday (m/d/yyyy) *
Email Address: *
Phone Number: *
May we contact you via text, phone & email? Check all that apply. *
Gerekli
Are you seeking individual or couples therapy? *
What is the reason for seeking therapy? *
Are you currently located in Hawaii? We are unable to provide services if you are not located in Hawaii.   *
Due to COVID-19, we are only meeting our clients via online sessions. Do you understand and acknowledge that your sessions will be held online until further notice? *
Do you plan to use your medical insurance? If so, what is the name of your carrier? *
What is your insurance subscriber number? *
When would be the best time to attend sessions?

*Evenings are the most requested times. We will do our best to provide an appointment at your preferred times, however, to assist you with providing an appointment as early as possible, please check off as many boxes that fit your preferred schedule.
*
Gerekli
If you have specific scheduling requests, please provide additional information below. 
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