Request an Appointment
For my safety I do a light screening for all new clients. Please fill out all sections.
Name
First Name
Last Name
Phone Number
E-mail
example@example.com
First Time Visit?
Yes
No
Select an Appointment Date
Age and Race
References: Names of other therapists you’ve met
Please attach a pic of your your ID, passport, LinkedIn or Costco card. You can hide any sensitive numbers. It’s simply so I know you’re safe and it’s discarded after you’re screened!
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After your hit submit send me a text to follow up and I will review your request
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