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Name *

First Name

Last Name

Phone *

(###)

###

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Patient's Date of Birth *

MM

DD

YYYY

Preference *

Telehealth Only

In-Person Only

Hybrid (I like a mix of telehealth and in-person)

No Preference

I understand EBTC does NOT accept insurance nor work with insurance companies. Fees are due at the start of session. *

Yes

I understand our fee range is $250-$300 (individual therapy 45 or 60 mins) *

Yes