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Name *

First Name

Last Name

Phone *

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What are you hoping to focus on in our work together? *

Select multiple options if needed.

Anxiety

Self-Criticism/Perfectionism

Trauma/PTSD

LGBTQ+ Identity Support

Something else (please explain below)

Fees *

I acknowledge that Dr Jenna Therapy PLLC does not accept insurance. The first 30-minute phone consultation is free. I understand that ongoing sessions are $200. I am prepared to submit payment at the time of service.