Couples Therapy Request Form
Let us know how we can help you!
What state are you currently located in?
*
California
Florida
Idaho
Kansas
Nevada
Tennessee
Texas
Other
Where are you looking to attend sessions?
In Person: Vacaville, CA
In Person: Roseville, CA
Online
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Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Partner's Name
*
First Name
Last Name
Partner's Phone Number
*
Please enter a valid phone number.
Partner's Email
*
example@example.com
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Availability
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Times
*
Mornings (8 AM - 12 PM)
Afternoons (12 PM - 4 PM)
Evenings (5 PM- 8 PM)
How did you hear about Freedom Counseling Group?
Internet Search/Google
Recommended by a friend or family meber
Recommended by a doctor
Other
Is there anything else we forgot to ask?
Let us know if there is any other information that would be helpful for us to be aware of as we match you. Please note we will need full names and email addresses for each potential participant if you are looking to participate in family or couples counseling.
Please verify that you are human
*
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