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Name

First Name

Last Name

Phone

(###)

###

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Client's Date of Birth

Type of Therapy Needed

Preferred Therapist - Subject to Fit & Availability

In alphabetic order

Preferred Format

Insurance Provider

Currently No Medicaid Plans Accepted

How did you hear about us?

Scheduling Needs

Are there times in the week that work really well for you? Times that don't work at all? Do you have flexibility with those times?

Message

Feel free to share more about what you want in a new therapist.

Office Location:

30 Jefferson Ave SE

Grand Rapids MI 49503

Current Standard Rate: $185

Let’s figure it out.