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Same Sex Couples Therapy

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Name*
Email*
Phone
Service Type
Preferred Location
- Petaluma
- Online
(Choose all that applies)
Referred by:
Comment or Message
Terms of Use
- Yes, I want to submit this form
By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Taggart Relationship Therapy harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.
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