Form

Please give us a call, send an email, or simply fill out the form on this page. We are looking forward to speaking with you.
We are committed to your privacy. Do not include confidential or private information regarding your health condition in this form or any other form found on this website. This form is for general questions or messages to the practitioner.
Full Name*

First NameLast Name
DOB*

MonthDayYear
Date
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Zip Code
Would you be interested in Tele-Therapy? (Optional)

Yes, I would be interested.
Will you be using insurance?*

YesNo
Insurance Information

If you would like us to check your benefits please provide ALL the information below.
Subscriber Name:

First NameLast Name
Subscriber DOB

MonthDayYear
Date
Relationship to Subscriber
Please upload your insurance card:

Front of card
Cancelof
Back of card
Cancelof
How did you hear about us? (Optional)

Internet SearchFriend, Family, or Word of MouthPsychology TodaySocial MediaDoctor/Medical PracticeOther
We are committed to your privacy. Do not include confidential or private information regarding your health condition in this form or any other form found on this website. This form is for general questions or messages to the practitioner.
Message (Optional)
Should be Empty:

Insurance Information