Puyallup Psychotherapeutic
         Alliance

Page 4

afarminlmhc@gmail.com
Phone: 253-686-1319

Contact Information

If you have any questions or would like to inquire about setting up counseling services, please fill out the form below.  Also, please include your availability and the best way to contact you.  If you have insurance, include the company so we may notify you of in network or out of network status.  Thank you.

First Name:
Last Name:
Phone #:
Cash/Insurance:
City:
Zip Code: (5 digits)
State:
Best method to contact you:
May I leave a message:
Email:
Comments:

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