Contact Us at Liv Mindfully | Clinical Psychologist

CONTACT

Are you willing to participate in remote Telehealth?*
- Yes
- No
Provider sees patients Mon - Friday 9 AM to 6 PM (EST). School and work excuse notes are available upon request. Is it possible to participate in therapy sessions during those hours?*
- Yes
- No
Full Name of Person Completing Form:*
First Last
Email Address:*
Name of New Patient:*
Patient Personal Phone Number or if Under 18, Parent/Legal Guardian Phone Number:*
Date of Birth of New Patient:*
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Patient Address:*
Street Address City State ZIP Code
How Did You Find Out About my Services:*
Very Briefly, Please Describe Your Reason for Seeking Services:*
If Patient is Located in MS, Who is the Patient’s Insurance Carrier:*
Insurance Policy ID Number:*
Name of Insured/Sponsor:*
Name of Insured/Sponsor Date of Birth*
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