Name *

Please specify the name of the person who will be receiving services. If services are for your child, please specify the child's name and date of birth.

First Name

Last Name

Client Date of Birth *

Please specify date of birth for the person who will be receiving services. If services are for your child, please specify the child's name and date of birth.

MM

DD

YYYY

Phone *

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###

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Disclaimer: *

Please be aware that information transmitted through this form is not secure or confidential. Do NOT send any personal or private health information through this form. By selecting the checkbox and submitting this form, you are releasing Graystone Therapy & Wellness Center, PLLC from any liability from such disclosures.

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