EMAIL CBT SPECTRUM

To make an appointment or to contact the office with questions

Full Name *

Full Name

First Name

Last Name

Date of Birth *

Email Address *

Phone Number *

Phone Number

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###

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Do you have Medicare *

What is the primary reason why you want to see a doctor? *

Will anyone potentially be joining your session? If yes, who? *

What is your general availability Monday-Thursday? (specify ALL available days/times) *

We will do our best to return your email within the week