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Free Consultation

Please use this form to book an initial 15 minute consultation. After completing this form, you will be redirected to the calendar to schedule your session.

Free Consultation Form

Name

Email

Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Date of Birth

What are you seeking treatment for?

What type of therapy are you seeking? Please select all that apply.

Anxiety

ADHD

Mood Disorders

Holistic Pain Management

PTSD

Severe Mental Illness

Substance Use Disorders

Depression

Individual Psychotherapy

Medication Management

Other

Do you live in the state of Arizona or California? (Please note: per state law, clients must reside in the state of Arizona or California in order to be seen for services)

Yes

No

How did you hear about Lateef Mental Wellness?