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AMBER FULLER

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First Name*
Last Name*
Email*
Phone*
I'm Interested In...*
What do you hope to get out of Plumline? (Select all that apply)*
- Healthier Relationships
- More Peace
- Life Clarity
- Heart Healing
- Increased Meaning
- Get Unstuck
- Other
Other:*
What day(s) work best for you to attend your Plumline experience?*
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Any of these days
What time of day works best for you to attend your Plumline experience?*
- Morning
- Lunchtime
- Afternoon
- Evening
- Any of these times
Have you done counseling or therapy previously?*
Have you considered or attempted harming yourself in the past 12 months?*
Do you have any questions or concerns about group work?
Consent*
I Agree
By providing personal information to us, you consent to us collecting, holding, and using your personal information in accordance with the Plumline Privacy Policy.
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Comments
This field is for validation purposes and should be left unchanged.