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Free of Mind Psychotherapy
Request for Services

Thank you for your interest in beginning therapy with Free of Mind Psychotherapy. Please complete the form below to request services. A member of our intake team will follow up within 1–2 business days to discuss availability, fit, and next steps.

Please note: Submitting this form does not guarantee services. We want to ensure we are the right clinical fit before scheduling an intake session.

CLIENT INFORMATION

THERAPY NEEDS

Are you seeking therapy for: (Check one)
Are you looking for: (Check one)
Preferred Days (Check all that apply):
Preferred Time of Day: (Check all that apply)

INSURANCE INFORMATION

Do you plan to use insurance? (Check one)

OTHER INFORMATION

How did you hear about us? (Check one)
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