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Teletherapy
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Teletherapy
Cognitive Behavior Therapy
Emotional Eating
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Hypnotherapy
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Getting Started
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Contact
Home
About
Teletherapy
Services
Teletherapy
Cognitive Behavior Therapy
Emotional Eating
Alcoholism & Codependency
Hypnotherapy
Deaf/Hard of Hearing
Energy Psychology
Getting Started
Fees and Payment Methods
Contact
Client Consent Form
Client Consent Form
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First Name
Last Name
Street Address
City / State / Zip
SSN
DOB
Phone Number
Ok to leave a voicemail?
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Single
Separated
Widowed
Email
*
Ok to send an email?
Employer or School
Occupation
Highest Level of education
Primary Physician
Phone
List any health conditions
List any medications you are taking and dosage
Have you seen a therapist before?
Yes
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Who may I thank for referring you?
Name of Emergency Contact
Relationship to you
Phone #
Do you consent?
*
Yes
No
By checking yes, you are indicating your consent to me contacting this person in an emergency and when I have been unable to reach you directly or in the case of an emergency for you.
Primary Insurer’s Name (if not “Self")
For Anthem Clients
Relationship to client:
H/Her Date of Birth:
Address (if different)
Insurance Company
Social Security #
Id # of Membership
Group #
Insurance Phone Number
Type your signature
By typing your name, you agreed to all the above information
Submit
CONTACT
703-731-4581
drnatalies@gmail.com
SERVICES
Emotional Eating
CBT
Energy Psychology
Alcoholism & Codependency
Meditation & Mindfulness
Deaf/HH
Hypnotherapy
LOCATION
7019 Backlick Ct. Springfield, VA 22151
Hours:
Monday through Friday: 9:00 am – 5:00 pm
WE ACCEPT
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