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**Please Note: This form is NOT for use in a mental health crisis. If you are in a crisis, please dial 9-1-1, go to the nearest emergency room, dial 9-8-8 or go to https://988lifeline.org.

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If seeking therapy, what are you hoping to address?

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For traditional therapy, Blue Cross Blue Shield (PPO) is the only insurance accepted. How do you plan to cover your services?

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