• Client Intake Form (*indicates a required field)

    Services provided by Shoshana Averbach, LMSW, MA , www.healingnotes.com
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  • Client Information

  • Services Needed

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  • Terms of Service, Disclaimer, Payment, Lateness/Cancellation Policy, and HIPAA Information

    We require 48-hour notice for unforeseen cancellations to avoid a fee.
  • TERMS OF SERVICE, HIPAA, Disclaimer, Cancellation/Lateness Policy--see www.healingnotes.com for the most current version. By signing the form below, the client indicates that s/he has read the aforementioned documents.

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  • We appreciate the time that you spent completing this form so we can help you! We will follow up with you shortly.

    Please contact us with any questions or concerns.

    Shalom and blessings!

    Shoshana Averbach

    LMSW, MA, MT-BC, LCAT, CDP, CCM, CECP, Accredited Healer

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