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JAKE SMITH JR.

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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.
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.