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Consultation Request Form

Please fill out the following form. 

*Please note that we are accepting clients age 25 and older. Clients must reside in either Fl, Ga, Tx.*

Have you attended therapy in the last 6 months?
Have you experienced any of the following in the last 12 months?
If seeking therapy services, I understand that Dr. Antionette is not accepting insurance at this time? *with the exception of Florida residents that have Aetna insurance

Thanks for submitting!

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