First Name
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Last Name
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Email
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Phone
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What state will you be located in for your appointments?
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Do you consent to email and/or text message notifications by Mindful Mental and Behavioral Health PLLC for the purpose of discussing services offered by our organization?*
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Yes, I consent to email and mobile phone text message notifications.
Yes, I consent to email notifications only.
Yes, I consent to mobile phone text message notifications only.
No, I do not consent to email and mobile phone text message notifications.
Any questions or additional information we should know:
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