i! · 2019-10-27 · ebony counseling consulting and supervision 1130 w. 6th ave ste 101 anchorage,...
Post on 30-Jun-2020
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IN CASE OF EMERGENCY
j Name of local friend or relative (not living at t same address):
, Relationship to , Client:
· Home phoneno.: Work phone no.:
I understand that I am liable for payment at the time of service. I understand that this is a self-pay service and that this is not therapy. No insurance will be billed for Life Coaching services.
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jClientl_9uardia�signature Date
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