Name *

First Name

Last Name

Phone *

(###)

###

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Service of interest *

Individual Counseling

LPC Clinical Supervision

Support Groups

Wellness Programs

Acknowledgment *

I understand that clinical services are offered only to individuals physically located in Pennsylvania at the time of the session. If I am outside Pennsylvania, therapy services cannot be provided until I am within the state. I also understand that completing this form does not create a contract for services with Peace Be Still Holistic Health, LLC, and that the decision to provide services is at the owner's discretion.

I agree