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Please Answer the following Questions to better help us assist you. your feedback is important to us!
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Age
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18-29
30-39
40-49
50-59
60+
Gender
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Male
Female
How did you hear about us?
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Insurance Plan
Friend/Family/Colleague
Community Event
Website
Google
Social Media
Print Media
Employment
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Unemployed
Part-time
Full-time
Student
Self-employed
Retired
Education
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Some High School
Completed High School
Some College
Associate's Degree
Bachelor's Degree
Master's Degree
Doctorate
Ethnicity
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African Descent
Asian
Caucasian
Hispanic
Native American
Other
In which area do you live?
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Baltimore County
Baltimore City
Howard County
Harford County
Montgomery County
Washington, DC
Other
Please identify the insurance company you plan to use or if you are using the ‘fee-for-service’ option.
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What services are you inquiring about?
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Stress, Anxiety, Trauma
Ultimate Healing Package
Work-Life Balance
Career Counseling
Test-Taking Anxiety
Detoxification for Addictions
Speaker
Check all that apply.
What would you like to do?
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Consultations are up to 30 minutes.
First and Last Name
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Please share your name with us so that we may address you upon contact. Your information is always confidential.
Email Address
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Phone Number
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Please share any additional information or comments regarding your inquiry.
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Home
The Ultimate Healing Package
STORE
Contact IPCH
IPCH Vantage Point (BLOG)
Questionnaire