Gina Brown Request Form
Let us know how we can help you!
Are you completing this form for yourself or for someone else?
Myself
Myself and a partner
My minor child
My adult child
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Where are you looking to attend sessions?
In Person: Vacaville, CA
Online (California)
What type of therapy are you looking for?
Individual
EMDR Therapy
Couple's Therapy
Family Therapy
Group Therapy
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Client's Name
*
First Name
Last Name
Client's Phone Number
*
Please enter a valid phone number.
Client's Email
*
example@example.com
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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
Thursday
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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