Consultation Form

Name *
Name
Phone *
Phone
Name of Spouse (or child)
Name of Spouse (or child)
Privacy and Security *
I understand that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information I include in an email can be intercepted and read by other parties besides the person to whom it is addressed. I also understand that Amy Standifer will coordinate our initial phone consult after I've scheduled it through Simple Practice. I give her permission to leave me a message at the phone number and email address provided.
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Amy Standifer MA, LPC
Owner / Therapist

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Nancy Wilkins MA, LPC-Intern
Supervised by
Scott Floyd, Ph. D., LPC-S, LMFT