Covid Response Client Form
Name
*
First Name
Last Name
Email
*
example@example.com
Join our Mailing List
Add my email to the Crossings Mailing List
Phone
*
-
Area Code
Phone Number
State you Live In
*
Maryland
District of Columbia
Virginia
*
We will contact you with three providers to choose from, and their contact information. We encourage you to choose a provider with whom you feel safe and comfortable.
*
At any time, you always are free to stop, pause, or discontinue these services.We ask that you give your provider at least 24 hours notice should you need to cancel or re-schedule for any reason.
*
This program is time-limited, and will end on August 5, 2020. After that date, should you wish to continue with your provider, it will be incumbent upon you to discuss your wishes with them and come to a financial agreement for ongoing services.
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