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First Name
Email
Last Name
Phone
Identify Area(s) of Struggle:
Depression/Anxiety
Pregnancy/Postpartum Mood Concerns
Sexual Issues (not including sex offenses/predatory behaviors)
Infertility Concerns
Relationship/Family Issues
Other (please describe in comments)
Insurance Plan
Cigna
Medica
UHC/UHG
UMR
UCare
Other Insurance Plan (please identify in comments)
N/A; Private Pay
What is your preference?
In-Person
Teletherapy
Either In-Person or Teletherapy
Who can we thank for connecting you with us?
Google Search
Provider Search through Insurance Plan
Psychology Today
Facebook
Therapy Den
Good Therapy
Open Path Collective
Postpartum Support International/Postpartum Support MN
Other (please describe in comments)
What are you looking for help with?
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