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New Client
2022-05-17T22:25:01+00:00
New Client
Want to book an Appointment with Kara? fill out the form below to be screened.
Full Name
*
Phone
*
Guardian Name
Guardian's Email
*
Date of Birth
*
Email
*
Guardian Phone Number
Address
*
Telehealth or In Person
*
Insurance
*
Responsible Party/Insurance Subscriber Name
*
Subscriber DOB
*
Subscriber/member ID Number
*
Group Number
*
Payor Number (some insurance cards only)
Referral Source
*
Email
*
Reason for Seeking Treatment
*
Submit
Thank you for your Inquire! Kara will be reaching out to you via Text Message and Email with Log In Information so that you can begin booking Appointments. Please Visit Frequently Asked Question Tab for further information.
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