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Full Name*
Email Address*
Phone Number*
City, State
What service are you most interested in?*
Free 15 min intake consultation
I need to schedule an appointment asap
I would like to setup recurring talk therapy sessions with you
Couples counseling session
Career Counseling Session
Webinar
Preferred Language*
Hindi
Bengali
English
Assamese
What concerns do you have?*
Emergency Contact's Name*
Emergency Contact's Email / Phone Number*
Relationship with Emergency Contact*
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You will be contacted within One business day
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Submit the Intake Form
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Need Help?
info@hopecanopy.com
Caution
: In the event of suicidal thoughts or a risk of self-harm, it is strongly recommended that you reach out to your nearest hospital for immediate assistance.
