Would you like to talk with me?

 Preliminary Information Form

After receiving your information form, we contact you by email and set up an appointment for me to talk with you.

  General Information
Your name:
Birth date:
Phone numbers:
Best times for us to call you:
Email:
Where you are located:
How you found me: Internet, Friend, Other
  About Your Situation
Your Diagnoses
Tell me about your current situation and what has you concerned.
  VOIP Services you have
Please mark which of these free, Internet VOIP services you have available at home
for me to use to talk
 and work with you:
Skype
Yahoo Messenger
Neither, but could install free software
Neither, and cannot install at home
 
 

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 Disclaimer Webmaster:
Last Updated: Tuesday, July 24, 2007 16:46:33 -0300