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TRAUMA THERAPY
Therapy Request Form
Full name
*
Email
*
Phone
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Where are you located?
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When do you want to begin? Select multiple if needed.
*
As soon as possible
Within the next six weeks
Between the next six weeks to three months
Between three to six months
After six months
Are you planning on in-person or remote therapy?
*
In-person
Remote
Both
What are you hoping to achieve through working with us? Please be thorough.
*
What is your previous experience with therapy? Please be as specific as possible.
*
Have you had psychedelic experiences before? If so, please tell us thorough details about your experience.
*
How did you hear about us? Please be as specific as possible.
*
Submit
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