What is your name?
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What is your email?
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What is your phone number?
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Date of birth
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Who referred you to Dr. Holmes' office?
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What exactly would you like Dr. Holmes to help you with?
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How committed are you to achieving this?
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Very committed (8-10)
Somewhat committed (5-7)
Not very committed (0-4)
Unsure
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Are you aware that health insurance typically does not cover this therapy?
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Yes
No
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What is your ability to invest in the mental health and wellness of yourself or a loved one?
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I have the financial resources to invest in the mental health and wellness of myself or a loved one.
I have access to resources to invest in the mental health and wellness of myself or a loved one.
I do not have the resources to invest in the mental health and wellness of myself or a loved one.
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