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Registration, and 

Terms of Service

(One form per person.)

This form is for NEW clients, and for those returning more than six months since their last appointment.

Enter your Insurance ID# here
Enter the name of the person who is "Primary" on your policy.
I authorize the following person to be contacted if I am unable to be reached.
Enter the name of your spouse or significant other if you are seeking marriage or relationship counseling.
(Brief description)
Terms of Service *
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Thank you! Your registration and appointment request was sent. Marney will contact you after he reviews your information.