Shermin Davis Appointment Request Form
Date of Birth
Referred By / How did you find me?
Dates, Days and/or Times that work for you
Meeting Options (check all that you are interested in)
Face to Face Online
Fee Options for Online & Phone Sessions
$150 per (50 minute) session
4 sessions at $100 per (50 minute) session
Sliding scale $85 - $140 per (50 minute) session based on need
Initial consultation $50 (25 minutes) or $100 (50 minutes)
Name of Insurance & Policy Number (and/or EAP Authorization)
Should be Empty:
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