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GOOD FAITH ESTIMATE REQUESTÂ
First Name
Last Name
Date of Birth
Email
Address
Housing
Employed
Job Title
Average Annual Income:
Total # of Members in Household:
Service Type
Desired Start Date:
Frequency of Services:
Weekly (52 Weeks Avg).
Bi-Weekly (24 Sessions Avg).
Monthly (12 Sessions Avg).
I have read and reviewed the following Terms and Conditions:
1.
Notice of Privacy Practices
2.
No Suprises Act
3.
Consent for Treatment
Request Good Faith Estimate
Please allow 3 business days for reply!
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