First Name
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Last Name
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Phone
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Email
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Address
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Location for services
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Broomfield
Denver
Telehealth only
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Insurance plan
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Aetna
Cigna
Colorado Medicaid
Kaiser
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UMR
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Email Risk Acknowledgement and Use Consent
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I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to WellMinded Counseling therapists and/or office staff communicating with me via email or text message
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