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What's your first name?

Last Name?

What's the best email address for you?

What's your phone number?

And what's your city, state & country?

What is your preferred means of communication?

Phone

Text

Are you interested in...

Group Therapy

Individual Therapy

Both

For individual therapy, how frequently would you like to see your therapist?

Weekly

More than once per week

Every other week

Are you requesting a specific therapist or are you open to seeing anyone on our team who has an opening?

What drew you to Firebird Healing? Did someone refer you?

What issues are you wanting to work on?

Have you had therapy on these issues in the past?

Thank you so much for submitting your Therapy Application Form. We'll contact you soon. In the mean time, check your email inbox.

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