Name
First Name
Last Name
Age
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Reasons for Seeking Therapy
Do you have a preference for Day of Week and Time of Day, or would you like a first available appointment?
How frequently do you prefer to meet?
Weekly
Every 2-3 Weeks
Monthly
Every 6-8 Weeks
Quarterly
I prefer to meet:
In Person: Tuscaloosa
Telehealth
Our rates are $150/Assessment and $130/55 minute session. Dana is currently private pay only and offers sliding scale payment options. Please select your preferred method of payment.
I plan to private pay
I would like to discuss sliding scale options
If you plan to utilize insurance, what kind of insurance do you have?
Do you have any questions before we schedule?
Check the box below to receive our weekly newsletter with mental health and wellness tips, resources, and more!
Yes, subscribe me to this newsletter.
How did you hear about Lifeline?
Submit
Should be Empty: