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I confirm that I am located in the State of California and will be for sessions.

By submitting this form through Restoring Vida Therapy’s web portal, I acknowledge and accept the risks associated with communicating personal and health information via unencrypted email and electronic messaging. I choose to proceed despite these risks and agree not to hold Restoring Vida Therapy liable for any unauthorized access, use, or disclosure of this information. I understand that if I become a client, I will be given access to a secure client portal for future communication.