Name *

First Name

Last Name

Phone *

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I understand that you are offering only online sessions at this time. *

Yes

By using this form, you acknowledge and accept the risks of communicating your personal health information via this unencrypted electronic messaging service and wish to continue despite those risks. By clicking the box below, you agree to hold Pinnacle Life Counseling, LLC harmless for any unauthorized access, use, or disclosure of your protected health information sent via the above message service. *

Yes