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Select your appointment - Yi-Chien Chang

* Addresses :

* Language:

* Type of appointment:

Adulte (60 minutes)

Adolescent 13 - 16 ans (60 minutes)

Adolescent 17 et + (60 minutes)

Couple (90 minutes)

Art-therapie (60 minutes)

* Place of consultation :

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* Civility

* Name:

* First name:

* Last name:

* First Name:

* Child's civility:

* Date of birth:

* First name partner:

* Name partner:

family composition

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* First name:

Name:

First name:

Name:

First name:

* E-mail:

* Mobile:

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* Postal code:

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* Address:

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I certify that the data provided are correct and I agree to notify the therapist at the latest 48 hours before the appointment if I will not be present. Otherwise the consultation will be due.

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KBC/CBC

Belfius

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