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Gayle Singer, L.C.S.W., Inc.  CA Lic #: 15307		gayle@childrenofdivorce.com
250 N. Robertson Blvd. Suite 425        Beverly Hills Hills, CA 90211			(310) 271-4749

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Thank you for your interest in the services of Gayle Singer, L.C.S.W., Inc. In the spaces below, please briefly describe your situation to Ms. Singer. In order for her to serve you best, please be prepared to arrange for a fee-based telephone assessment if you live in the State of California. Please note that an asterisk (*) denotes a required field: you must fill-in these blanks in order for this form to submit. To confirm that your message has been sent to Gayle Singer, you will be returned to the Children of Divorce Home Page after it has been transmitted. Please allow up to 14 days for a reply. For a faster response, please leave a voice messsage for Gayle Singer, L.C.S.W. at (310) 271-4749 between 10:00AM and 6:00PM Pacific Time, weekdays.

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I am a .... *	Child of Divorced Parents Divorced Parent Mental Health Professional Other
Your Name *
Your Email Address *
Daytime Telephone *
Mailing Address
City, State, Zip
My message concerns...	Please Select Making/canceling appointment Therapy for myself Therapy for my child Questions about my child's reaction to my divorce Questions about my reaction to my parent's divorce Other (specified below)
Details About My Situation *
Acknowledgement *	By checking this box, I understand and acknowledge that Gayle Singer, L.C.S.W. Inc. is basing a response to my inquiry solely on the information I have provided herein and I state that at all times this information is truthful to the best of my knowledge.
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