Phoenix Transformative

1

How did you hear about Phoenix Transformative?* This field is required.If applicable, who referred you?

2

Your Full Name* This field is required.

3

Best Phone Number To Reach You* This field is required.

4

Your Email Address* This field is required.

5

What is your relationship to the client?* This field is required.

6

Client Age?* This field is required.

7

Client Location?* This field is required.

8

What prompted you to reach out today?* This field is required.

9

Please briefly describe the current challenges and goals for support. * This field is required.

10

What date do you need support to begin?* This field is required.

Date

11

Please indicate Gender presentation that Client most closely identifies* This field is required.

Male

Female

Non-Binary

12

Are you seeking Treatment Placement?* This field is required.

YESNO

13

Are you seeking ongoing consultation while you navigate the treatment process?* This field is required.

YESNO

14

Please select Behavioral Health Consulting services below* This field is required.

Treatment Placement — $10,000

Ongoing 24/7 Monthly Consultation — $20,000

15

Are you seeking 24 hour in-person support?* This field is required.

YESNO

16

What level of 24 hour in-person support are you seeking?* This field is required.

Daily Support — $2,500

Weekly Engagement — $15,000

Monthly Engagement — $60,000

90-Day Commitment — $50,000/month

17

What level of Concierge Support are you seeking?* This field is required.Includes 10 hours of in-person support per week, in addition to 24/7 phone support.

Weekly Engagement — $8,000

Monthly Engagement — $30,000

90-Day Commitment — $25,000/month

18

All services are prepaid in advance and payment is required prior to the start of services. Due to the nature of reserving time, availability, and support capacity, all payments are non-refundable.* This field is required.Please acknowledge:

I understand and acknowledge the payment policy.