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GET IN TOUCH

1212 N Washington St, Suite 327

Spokane, WA 99201

info@elitemindspllc.com

509-505-4567

Client Name

Your Name & Relationship

Phone

Address

Email

Birthday

Sport

Gender

Referred by

Referred to

Services preference

Individual Counseling

Coaching

Both

Unsure

Team Workshops

Free 15 Minute Phone Consultation

College Recruiting Counseling

Student-Athlete Counseling

Marriage/Relationship Counseling

Reason for services

***Only complete the insurance section below if you are seeking sports counseling services

Primary Insurance

Phone

Policy #

Group #

We will be in touch ASAP!

info@elitemindspllc.com

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