Full Name
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Phone
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Email
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Reason For Appointment (Multiple Choice):
Reason For Appointment
Adult ADHD
Anxiety
Depression
Insomnia
Women's Health
Bipolar Disorder
Other
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Office location
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Location of Interest
Dallas
Houston
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Insurance/Reimbursement Info
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Cigna
Magellan/BCBS HMO Blue Advantage
Other - Interested as out of network patient
Self-Pay Patient
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