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ESA Evaluation

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Full Name*

First NameLast Name
Date of Birth*
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Phone Number*
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Administrative Sex*
Gender Identity*
Email Address*
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Address*

Street Address

Street Address Line 2

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Postal / Zip Code
Service Preference*
Marital Status*

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Employment Status*

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Group Therapy Preference (If Applicable)?
What is your time preference? (Select all that apply)*

Morning 8:00 AM - 12:00 PMAfternoon 12:00 PM - 5:00 PMEvening 5:00 PM - 8:00 PMFully Open Availability
What days of the week do you prefer? (Select all that apply)*

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I understand that the evaluation fee is non-refundable, regardless of whether I am deemed appropriate for an ESA recommendation. I agree to the total fee of $150 and acknowledge that this fee must be paid in full prior to the evaluation.*

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ESA Evaluation